Initial Workup for Hematospermia in a 36-Year-Old Male
For a 36-year-old male presenting with hematospermia, the initial workup should include a detailed history, physical examination, and basic laboratory tests, as imaging is generally not recommended for this age group with transient episodes and no other symptoms.1
Initial Assessment
History
- Determine if hematospermia is transient/episodic or persistent
- Assess for associated symptoms:
- Fever, chills
- Dysuria, urinary frequency/urgency
- Perineal or pelvic pain
- Weight loss
- Sexual history including recent partners and potential STIs
- Recent urogenital procedures or trauma
- History of bleeding disorders
Physical Examination
- Vital signs including blood pressure (hypertension can be associated)
- Genital examination:
- Inspect penis and urethral meatus
- Palpate testes and measure size
- Check for presence and consistency of vasa and epididymides
- Assess for varicocele
- Digital rectal examination to evaluate prostate
Laboratory Testing
- Urinalysis
- Urine culture
- STI testing (particularly for gonorrhea and chlamydia)
- Complete blood count
- Serum coagulation studies
- Serum chemistry panel
- Visual analysis of ejaculate for red discoloration
Management Based on Findings
For Uncomplicated Cases (Most 36-year-olds)
For men under 40 years with transient/episodic hematospermia and no other symptoms or risk factors, the condition is typically benign and self-limiting 1, 2. In these cases:
- Reassurance is appropriate
- No imaging is generally recommended
- Watchful waiting and routine clinical evaluation are sufficient
When Further Investigation Is Needed
Further workup is indicated if the patient has:
- Persistent hematospermia
- Associated symptoms (fever, pain, weight loss)
- Risk factors (history of cancer, urogenital malformations, bleeding disorders)
In these cases, consider:
Transrectal ultrasound (TRUS) as first-line imaging
- Highly sensitive (82-95%) for detecting abnormalities 1
- Can identify calcifications, cysts, hypertrophy, inflammation
If TRUS is negative or inconclusive:
- MRI pelvis without and with IV contrast 1
- Superior soft tissue contrast for evaluating prostate and seminal tract
Important Considerations
- Hematospermia in younger men is most commonly due to infectious or inflammatory conditions (approximately 40% of cases) 1
- Urogenital infections are the second most common cause after iatrogenic trauma 3
- Single episodes in men under 40 without risk factors generally do not require extensive workup 2, 4
- The condition is often self-limiting and benign in this age group 5
Common Pitfalls to Avoid
- Failing to distinguish between transient and persistent hematospermia
- Overlooking sexually transmitted infections as a common cause in younger men
- Unnecessary imaging in uncomplicated cases
- Neglecting to reassure the patient about the typically benign nature of the condition
By following this approach, clinicians can provide appropriate care while avoiding unnecessary testing for this often benign condition in younger men.