What is the appropriate management for spermatochezia?

Management of Spermatochezia (Blood in Semen)

Spermatochezia (blood in semen) is typically a benign, self-limiting condition that rarely indicates serious underlying pathology, particularly in men under 40 years of age, but requires systematic evaluation to rule out significant causes, especially in older men or those with persistent symptoms.

Etiology and Risk Stratification

Age-Based Risk Assessment

• Men under 40 years: Usually benign causes (inflammation, infection)
• Men over 40 years: Higher risk of underlying serious pathology 1

Common Causes

1. Inflammatory/infectious processes (most common)

   • Prostatitis
   • Urethritis
   • Epididymitis
   • Seminal vesiculitis

2. Anatomical abnormalities

   • Ejaculatory duct obstruction
   • Seminal vesicle cysts

3. Iatrogenic causes

   • Recent prostate biopsy
   • Urological procedures

4. Vascular abnormalities

   • Prostatic varices
   • Vascular malformations

5. Malignancy (rare, but more common in men >40)

   • Prostate cancer
   • Testicular cancer
   • Seminal vesicle tumors

Diagnostic Approach

Initial Evaluation

1. Detailed history

   • Duration and frequency of episodes
   • Associated symptoms (pain, urinary symptoms, fever)
   • Recent procedures or trauma
   • Sexual history and practices

2. Physical examination

   • Blood pressure assessment
   • Genital examination
   • Digital rectal examination (DRE)
   • Assessment for testicular abnormalities

Laboratory Testing

1. Urinalysis and urine culture
2. Semen analysis and culture
3. STI screening if indicated
4. PSA testing in men over 40 years 1

Imaging Studies (Based on Risk Factors)

1. Transrectal ultrasound (TRUS) - first-line imaging for persistent or recurrent cases 2
2. Scrotal ultrasound with Doppler - if testicular pathology is suspected 3
3. MRI of pelvis - for complex or suspicious cases 2

Invasive Procedures (When Indicated)

1. Cystoscopy - for persistent cases or when bladder/urethral pathology is suspected
2. Prostate biopsy - when prostate cancer is suspected

Management Algorithm

Single Episode in Men <40 Years Without Risk Factors

1. Reassurance - typically self-limiting
2. Consider STI screening and treatment if indicated
3. Follow-up only if symptoms persist

Persistent or Recurrent Episodes in Men <40 Years

1. Urinalysis and urine culture
2. Semen analysis and culture
3. Transrectal ultrasound
4. Empiric antibiotics if infection is suspected
5. Follow-up in 4-6 weeks

Any Episode in Men ≥40 Years or With Risk Factors

1. Complete evaluation including PSA testing
2. Transrectal ultrasound
3. Consider MRI for suspicious findings
4. Urological referral for further management

Treatment Based on Etiology

1. Infectious causes: Appropriate antibiotics based on culture results

   • For prostatitis: fluoroquinolones or trimethoprim-sulfamethoxazole for 2-4 weeks
   • For STIs: Follow CDC treatment guidelines 4

2. Inflammatory causes: Anti-inflammatory medications, alpha-blockers

3. Ejaculatory duct obstruction: Transurethral resection of ejaculatory ducts (TURED) may be considered 4

4. Malignancy: Definitive treatment of primary lesion 2

Follow-up Recommendations

1. Single episode that resolves: No specific follow-up needed
2. Persistent symptoms: Re-evaluation at 4-6 weeks
3. Recurrent episodes: Consider more extensive workup including cystoscopy and MRI

Important Considerations

• Patient anxiety: Provide reassurance about the typically benign nature of the condition
• Avoid unnecessary invasive procedures in young men with single episodes
• Be vigilant in men >40 years due to higher risk of underlying malignancy
• Consider urological referral for persistent, recurrent, or concerning cases

Red Flags Requiring Urgent Evaluation

• Concurrent hematuria
• Significant pain
• Systemic symptoms (fever, weight loss)
• Abnormal DRE findings
• Elevated PSA in men >40 years
• Family history of genitourinary malignancies

Remember that while most cases of spermatochezia are benign, a systematic approach to evaluation is essential to identify the small percentage of cases that may indicate serious underlying pathology.