What is the appropriate evaluation and management for a patient presenting with hematospermia?

Evaluation and Management of Hematospermia

For patients presenting with hematospermia, age-stratified evaluation is essential, with men under 40 years with isolated episodes typically needing only basic assessment, while men over 40 years or those with persistent symptoms require thorough evaluation including PSA testing and imaging. 1

Initial Assessment

History

• Duration: Single episode vs. persistent/recurrent
• Associated symptoms: Fever, pain, weight loss, lower urinary tract symptoms
• Risk factors: Recent procedures, trauma, STIs, cancer history
• Sexual history: New partners, unprotected intercourse
• Medication use: Anticoagulants, antiplatelet agents

Physical Examination

• Blood pressure measurement (hypertension can contribute)
• Abdominal examination
• Genital examination
• Digital rectal examination (essential in men ≥40 years)

Basic Laboratory Testing

• Urinalysis and urine culture
• STI testing when indicated
• PSA testing (for men ≥40 years)

Diagnostic Algorithm

Men <40 years with single/transient episode

• If normal physical exam and no concerning symptoms:
  • Reassurance and watchful waiting
  • No imaging typically required 2, 1
• If associated with lower urinary tract symptoms:
  • Urinalysis and STI testing
  • Treatment of identified infections 3

Men ≥40 years OR persistent/recurrent hematospermia OR concerning symptoms

1. Basic evaluation as above plus PSA testing
2. Imaging studies:
   • Transrectal Ultrasound (TRUS) as first-line imaging (detection rate 82-95%) 1
   • MRI of prostate and seminal tract if TRUS is negative/inconclusive 2, 1
   • CT has limited value due to poor soft tissue contrast 1

Management Approach

Targeted Treatment

• Infections: Appropriate antimicrobial therapy based on identified pathogen
• Inflammatory conditions: Anti-inflammatory medications
• Structural abnormalities: Surgical intervention when indicated
• Malignancy: Referral to appropriate specialist

Idiopathic Cases

• Reassurance (most cases are self-limiting)
• Follow-up to ensure resolution
• Consider urological referral for persistent cases

Special Considerations

Common Pitfalls

1. Overinvestigation in young patients with single episodes - extensive workup rarely needed 1
2. Underinvestigation in older men - PSA and imaging are essential 1
3. Focusing only on prostate - seminal vesicles and ejaculatory ducts are common sources 1
4. Overlooking systemic causes - check hypertension and coagulation status 1, 4

Red Flags Requiring Prompt Evaluation

• Age ≥40 years
• Persistent or recurrent hematospermia
• Associated symptoms (fever, weight loss, bone pain)
• Abnormal digital rectal examination
• Elevated PSA
• Hematuria

Evidence Quality

The American College of Radiology guidelines 2 and comprehensive clinical summaries 1 provide strong recommendations for age-stratified evaluation. These are supported by multiple clinical studies 3, 5, 6, 7, 4 that consistently show hematospermia is typically benign in younger men but warrants more thorough investigation in older men or when persistent.

The evidence consistently supports that transrectal ultrasound should be the first-line imaging modality, with MRI reserved for cases where TRUS is inconclusive or negative 2, 1, 6.