What are the causes of hematospermia (blood in semen)?

From the Guidelines

Hematospermia, or blood in the semen, is most commonly caused by infectious or inflammatory conditions, accounting for approximately 40% of cases, with the majority of cases occurring in men under 40 years of age 1. The causes of hematospermia can be varied, but the most common etiologies include:

• Inflammatory or infectious conditions such as prostatitis or seminal vesiculitis
• Prior prostatic biopsy
• Prostatic calculi
• Ductal obstruction
• Prostatic cyst formation
• Vascular malformations According to the American College of Radiology Appropriateness Criteria, infections of the urogenital tract are the most common identifiable cause of hematospermia 1.

Key Considerations

When evaluating hematospermia, it is essential to consider the patient's age, symptoms, and medical history.

• For most young men with isolated hematospermia and no other symptoms, watchful waiting is appropriate.
• However, medical evaluation is recommended if hematospermia persists beyond 4-6 weeks, recurs frequently, is accompanied by other symptoms like pain or urinary problems, or occurs in men over 40.

Diagnostic Approach

Noninvasive imaging, predominantly transrectal ultrasound (TRUS) and MRI, can be used in men of any age with persistent or refractory hematospermia, or other associated symptoms or signs 1. The first-line imaging modality for evaluating hematospermia is transrectal ultrasound (TRUS), with MRI used when TRUS is inconclusive or negative 1.

From the Research

Causes of Hematospermia

The causes of hematospermia can be varied and are often categorized by age group.

• In men younger than 40 years, common causes include:
  • Sexually transmitted infections or other urogenital infections 2, 3
  • Inflammatory and infective pathologies 3
• In men 40 years and older, common causes include:
  • Iatrogenic hematospermia from urogenital instrumentation or prostate biopsy 2, 4
  • Genitourinary infections, inflammations, vascular malformations, stones, tumors, and systemic disorders that increase bleeding risk 2
  • Malignant disorders, such as prostate, testis, and seminal vesicle cancers 3
• Other possible causes of hematospermia include:
  • Trauma 4, 5
  • Bleeding from the seminal vesicle 6
  • Systemic causes, such as arterial hypertension or hematologic disorders 4
  • Predisposing diseases, such as prostatitis, epididymitis, urinary stones, tuberculosis, cirrhosis of the liver, and hematologic diseases 5

Diagnostic Evaluation

A diagnostic evaluation for hematospermia should include:

• A thorough medical history and physical examination, including a digital rectal examination and laboratory tests, such as urinalysis and prostate-specific antigen testing 2, 3, 4
• Further testing, such as transrectal ultrasonography, magnetic resonance imaging, and urethrocystoscopy, may be necessary in some cases 3, 4, 5
• A single episode of hematospermia in men under 40 may be evaluated with a basic diagnostic evaluation, while repeated episodes or hematospermia in men over 40 may require additional evaluation 4