What is the treatment approach for patients presenting with hematospermia?

Treatment Approach for Hematospermia

The treatment approach for hematospermia should be stratified by age, with patients under 40 years typically requiring only reassurance and minimal evaluation, while those over 40 or with persistent symptoms warrant more thorough investigation including transrectal ultrasound as first-line imaging. 1

Age-Based Approach

Patients Under 40 Years

• For young men (<40 years) with transient/episodic hematospermia without other symptoms:

  • Reassurance and watchful waiting are sufficient 1, 2
  • No imaging is typically required 1
  • Basic evaluation includes:
    • Detailed history focusing on duration and frequency
    • Physical examination
    • Urinalysis
    • Testing for sexually transmitted infections if suspected 2

• For young men with associated symptoms (dysuria, frequency, urgency):

  • Evaluate for genitourinary infections (most common cause in this age group) 1, 3
  • Treatment with appropriate antibiotics if infection is confirmed 3

Patients 40 Years and Older or With Persistent Symptoms

• For men ≥40 years OR persistent/recurrent hematospermia OR associated symptoms:
  • More thorough evaluation is warranted 1, 2
  • Digital rectal examination and PSA testing to evaluate for prostate cancer 2
  • Transrectal ultrasound (TRUS) as first-line imaging 1
  • MRI if TRUS is negative or inconclusive 1

Diagnostic Algorithm

1. Initial Assessment:

   • Medical history focusing on:
     • Duration (transient vs. persistent)
     • Associated symptoms (pain, fever, LUTS)
     • Risk factors (recent procedures, trauma, anticoagulation)
   • Physical examination including digital rectal examination
   • Laboratory tests: urinalysis, urine culture, STI testing

2. Imaging Based on Risk Stratification:

   • Low risk (age <40, single episode, no symptoms):
     • No imaging needed
   • High risk (age ≥40, persistent/recurrent, associated symptoms):
     • TRUS as first-line imaging (rated 8/9 for appropriateness) 1
     • MRI pelvis if TRUS is negative or inconclusive (rated 7-8/9) 1
     • CT and angiography are not recommended (rated 1-2/9) 1

Treatment Based on Etiology

1. Infectious/Inflammatory Causes:

   • Appropriate antimicrobial therapy based on culture results
   • Anti-inflammatory medications for non-infectious inflammation

2. Structural Abnormalities:

   • Management of prostatic calculi, cysts, or ejaculatory duct obstruction if identified
   • Consider transurethral resection of ejaculatory ducts (TURED) for confirmed obstruction

3. Malignancy:

   • Appropriate oncologic referral and management if cancer is detected

4. Idiopathic Cases:

   • Reassurance about benign nature
   • Follow-up if symptoms persist or worsen

Important Clinical Pearls

• Hematospermia is typically benign and self-limiting in most cases 2, 3
• Infectious/inflammatory conditions account for approximately 40% of cases overall 1
• TRUS has high sensitivity, detecting abnormalities in 82-95% of men with hematospermia 1
• Common findings on imaging include calcifications/calculi, cysts, and inflammatory changes 1

Common Pitfalls to Avoid

• Overinvestigation in young men with transient episodes
• Underinvestigation in older men or those with persistent symptoms
• Delayed evaluation in patients with risk factors for malignancy
• Attributing to infection without appropriate testing
• Failing to recognize iatrogenic causes (e.g., post-prostate biopsy)

By following this structured approach, clinicians can effectively manage patients with hematospermia while avoiding unnecessary testing in low-risk cases and ensuring appropriate evaluation in those at higher risk for significant underlying pathology.