What is the initial workup for a 35-year-old presenting with hematospermia (bloody semen)?

Initial Workup for Hematospermia in a 35-Year-Old

For a 35-year-old man presenting with hematospermia, the initial workup should include a detailed history, physical examination, urinalysis, and testing for sexually transmitted infections, as imaging is not generally recommended for this age group with transient episodes. 1

Age-Based Approach

For Men Under 40 Years (Like Our Patient)

• Hematospermia in younger men is typically benign and self-limiting
• Watchful waiting, reassurance, and routine clinical evaluation are usually sufficient 1
• No imaging is generally recommended for transient/episodic hematospermia without other symptoms 1

Initial Evaluation Should Include:

1. Detailed History:

   • Duration of hematospermia (transient vs. persistent)
   • Associated symptoms (pain, fever, weight loss)
   • Sexual history (recent partners, unprotected intercourse)
   • Trauma history (including sexual practices)
   • Recent urologic procedures
   • Medication use (especially anticoagulants)
   • History of bleeding disorders

2. Physical Examination:

   • Genital examination
   • Digital rectal examination to assess prostate
   • Check for discharge, lesions, or inflammation

3. Laboratory Testing:

   • Visual analysis of ejaculate for red discoloration
   • Urinalysis and urine culture
   • STI testing (gonorrhea, chlamydia, etc.)
   • Semen analysis
   • Assessment of serum coagulation
   • Complete blood count
   • Serum chemistry panel 1

When to Consider Additional Evaluation

Additional evaluation should be considered in the following circumstances:

• Age ≥40 years
• Persistent hematospermia (recurring over weeks to months)
• Associated symptoms such as:
  • Fever
  • Significant pain
  • Weight loss
  • Hematuria
  • Lower urinary tract symptoms 1, 2

Advanced Imaging (When Indicated)

For patients meeting the criteria above, further imaging may include:

1. Transrectal Ultrasound (TRUS):

   • First-line imaging tool for persistent cases
   • Can detect abnormalities in 82-95% of men with hematospermia
   • Can identify calcifications, cysts, BPH, prostatitis 1

2. MRI:

   • Provides radiation-free, high-resolution evaluation
   • Useful when TRUS is unsatisfactory or nondiagnostic
   • Better soft tissue contrast than other modalities 1

3. CT:

   • Limited value due to poor soft tissue contrast
   • Can identify calcifications, gross masses, or cystic lesions 1

Common Pitfalls to Avoid

• Causing unnecessary anxiety by extensive workup in young men with isolated episodes
• Failing to rule out STIs, which are common causes in men under 40
• Missing systemic conditions that increase bleeding risk
• Overlooking the possibility that blood may be from a sexual partner rather than the patient 1, 2

Follow-up Recommendations

• For isolated episodes in men <40 without risk factors: reassurance and observation
• For suspected infection: treat according to identified pathogen
• For persistent cases: referral to urology for consideration of advanced imaging 2, 3

By following this approach, most cases of hematospermia can be effectively managed in the primary care setting, with appropriate referral when indicated by age, persistence, or associated symptoms.