What is the appropriate work up for a patient presenting with hematospermia and groin pain?

Workup for Hematospermia with Groin Pain

For a patient presenting with hematospermia and groin pain, the recommended initial workup should include transrectal ultrasound (TRUS) as first-line imaging, followed by MRI if TRUS is inconclusive or negative. 1

Initial Assessment

History and Physical Examination

• Focus on:
  • Patient age (different approach for <40 vs ≥40 years)
  • Duration of hematospermia (transient/episodic vs persistent)
  • Associated symptoms (fever, weight loss, dysuria)
  • Groin pain characteristics (location, radiation, exacerbating factors)
  • Recent urogenital procedures or trauma
  • Sexual history and potential STIs
• Complete physical examination including:
  • Digital rectal examination to assess prostate
  • Testicular examination (size, consistency, descent) 2
  • Evaluation for inguinal hernia or lymphadenopathy
  • Assessment for signs of infection or inflammation

Laboratory Testing

• Urinalysis and urine culture
• STI testing (gonorrhea, chlamydia)
• PSA testing (for men ≥40 years) 1
• Complete blood count
• Semen analysis and culture
• Coagulation studies if recurrent bleeding 1

Imaging Recommendations

For Patients <40 Years with Transient Hematospermia

• If isolated episode without other symptoms: no imaging required 1
• If persistent or associated with groin pain:
  1. TRUS as first-line imaging 1
  2. MRI if TRUS is inconclusive 1

For Patients ≥40 Years or Any Age with Persistent Symptoms

1. TRUS (first-line imaging) 1

   • Highly sensitive (82-95%) for detecting abnormalities 1
   • Can identify:
     • Prostatic calcifications/calculi
     • Seminal vesicle abnormalities
     • Ejaculatory duct obstruction
     • Prostatic cysts or masses
     • Signs of prostatitis

2. MRI (if TRUS inconclusive or negative) 1

   • Superior soft tissue contrast
   • Better evaluation of seminal vesicles and ejaculatory ducts
   • Should include T1 and T2-weighted images of prostate and seminal tract

3. CT scan (limited role)

   • Not recommended as primary imaging due to limited soft tissue contrast 1
   • May identify gross calcifications or masses

4. Pelvic angiography (rare cases)

   • Reserved for intractable hematospermia when other evaluations are negative
   • Can identify and treat vascular causes via embolization 1

Common Causes to Consider

Infectious/Inflammatory

• Prostatitis
• Seminal vesiculitis
• Urethritis
• STIs (most common cause in men <40 years) 1, 3

Obstructive

• Ejaculatory duct obstruction
• Seminal vesicle or prostatic cysts
• Calcifications in prostate or seminal vesicles 1

Trauma/Iatrogenic

• Recent prostate biopsy
• Urogenital instrumentation (common in men >40 years) 3

Neoplastic (more common in men >40)

• Prostate cancer
• Seminal vesicle tumors 1, 3

Special Considerations

For Groin Pain

• Consider additional evaluation for:
  • Epididymitis
  • Testicular torsion
  • Inguinal hernia
  • Referred pain from kidney stones 1

Pitfalls to Avoid

• Don't dismiss persistent hematospermia in men ≥40 years without thorough evaluation
• Don't attribute groin pain solely to hematospermia without ruling out other causes
• Remember that "idiopathic" should be a diagnosis of exclusion after appropriate workup
• Don't miss the opportunity to screen for prostate cancer in men ≥40 years with PSA and DRE

Management Algorithm

1. Initial presentation:

   • If <40 years with single episode: reassurance and follow-up
   • If ≥40 years OR persistent/recurrent OR with groin pain: proceed with full workup

2. Laboratory workup:

   • Basic: Urinalysis, urine culture, STI testing
   • Additional: PSA (if ≥40 years), CBC, coagulation studies

3. Imaging:

   • First-line: TRUS
   • Second-line: MRI if TRUS inconclusive or negative

4. If specific etiology identified:

   • Treat according to cause (antibiotics for infection, surgical intervention for obstruction, etc.)

5. If workup negative:

   • Consider urologic consultation
   • Reassurance and symptomatic management
   • Follow-up if symptoms persist or worsen

By following this structured approach, clinicians can effectively evaluate patients with hematospermia and groin pain, ensuring appropriate management while avoiding unnecessary testing.