What are the causes and management of hematospermia in transfeminine patients?

Causes and Management of Hematospermia in Transfeminine Patients

Hematospermia in transfeminine patients is primarily caused by estrogen-related vascular changes, inflammatory conditions of the prostate and seminal vesicles, and anatomical alterations due to hormone therapy, requiring evaluation with transrectal ultrasound as first-line imaging for persistent cases.

Etiology of Hematospermia in Transfeminine Patients

Hormone-Related Causes

• Estrogen-induced vascular changes: Gender-affirming hormone therapy (GAHT) with estrogen can cause prothrombotic effects that may lead to microhemorrhages in the seminal tract 1
• Prostate and seminal vesicle inflammation: Hormonal changes can alter the tissue architecture of the prostate and seminal tract, potentially leading to inflammatory conditions 1
• Decreased ejaculatory duct elasticity: Estrogen therapy may affect tissue elasticity, potentially leading to microtrauma during ejaculation

Non-Hormonal Causes (Similar to Cisgender Men)

• Infectious/inflammatory processes: Most common cause (approximately 40% of cases), especially in patients under 40 years 1, 2
• Prostatic calculi or cysts: Can develop regardless of hormone status 1
• Ejaculatory duct obstruction: May be exacerbated by hormonal changes 1
• Vascular malformations: Rarely can be a source of bleeding 1, 3

Diagnostic Approach

Initial Evaluation

1. Risk stratification based on age and symptoms:

   • Single episode in patients <40 years without risk factors: Often benign and self-limiting 4, 2
   • Persistent/recurrent hematospermia or age >40 years: Requires thorough evaluation 1, 5

2. Physical examination:

   • Blood pressure measurement (hypertension can contribute to hematospermia) 6
   • Genital examination for testicular abnormalities 5
   • Digital rectal examination to assess prostate 1, 5

3. Laboratory testing:

   • Urinalysis and urine culture
   • Testing for sexually transmitted infections
   • PSA testing (especially in patients >40 years) 2

Imaging Studies for Persistent Cases

1. Transrectal ultrasound (TRUS):

   • First-line imaging modality (rated 8/9 for appropriateness) 1
   • Highly sensitive (82-95% detection rate for abnormalities) 1
   • Can identify calcifications, cysts, inflammation, and structural changes 1

2. MRI of pelvis:

   • Second-line imaging when TRUS is negative or inconclusive (rated 7-8/9 for appropriateness) 1
   • Superior soft tissue contrast for evaluating prostate and seminal tract 1, 3
   • Can detect subtle abnormalities not visible on TRUS 1

3. CT and angiography:

   • Limited value (rated 1-2/9 for appropriateness) 1
   • Reserved for specific cases where vascular malformation is suspected 1

Management Approach

For Single Episode Without Risk Factors

• Reassurance (most cases are benign and self-limiting) 4, 2
• Consider watchful waiting with routine clinical follow-up 1

For Infectious/Inflammatory Causes

• Appropriate antibiotic therapy for confirmed infections
• Anti-inflammatory medications for non-infectious inflammation

For Persistent/Recurrent Cases

• Treatment directed at underlying cause identified through imaging 6
• Consider referral to urology for specialized management

Special Considerations for Transfeminine Patients

• Monitor for thrombotic risk due to estrogen therapy 1
• Consider adjusting hormone regimen if recurrent episodes occur, particularly if using ethinyl estradiol (which carries higher VTE risk) 1
• Be aware that progestins combined with estrogens may increase cardiovascular risk factors 1

Important Caveats

• Anxiety management: Hematospermia often causes significant patient anxiety despite usually being benign 4, 5
• Age-related risk: Higher suspicion for serious pathology in patients >40 years 1, 2
• Hormone considerations: Transfeminine patients on GAHT have unique physiological considerations that may affect both the cause and management of hematospermia 1
• Imaging limitations: Some transfeminine patients may have anatomical considerations that preclude the use of endorectal coils for MRI 1

By following this structured approach to evaluation and management, most cases of hematospermia in transfeminine patients can be appropriately addressed while minimizing unnecessary testing and patient anxiety.