What is the recommended workup for a patient presenting with hematospermia?

Hematospermia Workup

The recommended workup for hematospermia should be age-stratified, with men under 40 years with isolated episodes requiring only basic evaluation, while men ≥40 years or those with persistent symptoms need thorough evaluation including PSA testing and imaging. 1

Initial Assessment

History

• Duration and frequency (single episode vs. persistent/recurrent)
• Associated symptoms (pain, fever, weight loss, urinary symptoms)
• Risk factors (recent procedures, trauma, infections)
• Sexual history
• Medication use (anticoagulants)
• Systemic conditions (hypertension, bleeding disorders)

Physical Examination

• Blood pressure measurement (hypertension is a potential cause)
• Abdominal examination
• Genital examination
• Digital rectal examination (essential, especially in men ≥40)

Age-Based Diagnostic Algorithm

For Men <40 Years with Single/Transient Episode

• If normal physical examination and no associated symptoms:
  • Reassurance and watchful waiting
  • No imaging typically required 1
  • Urinalysis
  • Testing for sexually transmitted infections if suspected 2

For Men ≥40 Years OR Persistent/Recurrent Symptoms OR Abnormal Findings

1. Basic laboratory tests:

   • Urinalysis and urine culture
   • PSA testing
   • Consider coagulation studies if bleeding disorder suspected

2. Imaging studies:

   • Transrectal Ultrasound (TRUS) as initial imaging (detection rate 82-95%)

     • Can identify prostatic calcifications, seminal vesicle abnormalities, ejaculatory duct obstruction, cysts, masses, and prostatitis 1

   • If TRUS is negative or inconclusive:

     • MRI of prostate and seminal tract
     • Superior soft tissue contrast and visualization of seminal vesicles and ejaculatory ducts 1, 3

3. Additional tests based on findings:

   • Cystoscopy if bladder pathology suspected
   • Semen culture if infection suspected

Special Considerations

Common Pitfalls to Avoid

• Overinvestigation in young patients with single episodes - extensive workup rarely needed 1
• Underinvestigation in older men - PSA and imaging are essential 1
• Focusing only on prostate - seminal vesicles and ejaculatory ducts are common sources 1
• Neglecting systemic causes like hypertension and coagulation disorders 4

When to Refer to Urology

• Men ≥40 years with hematospermia
• Persistent or recurrent hematospermia
• Abnormal findings on initial evaluation
• Associated symptoms (fever, pain, weight loss)
• Elevated PSA
• Abnormal imaging findings

Management Approach

• Treatment should target the underlying cause when identified:

  • Infections: appropriate antimicrobial therapy
  • Inflammatory conditions: anti-inflammatory medications
  • Structural abnormalities: may require surgical intervention
  • Malignancy: referral to appropriate specialist 1

• For idiopathic cases, especially in younger men:

  • Reassurance is often sufficient as most cases are self-limiting 1, 5
  • Follow-up to ensure resolution

By following this structured approach, clinicians can efficiently evaluate patients with hematospermia while avoiding unnecessary testing in low-risk cases and ensuring thorough evaluation in higher-risk scenarios.