Can hematospermia occur after prostatectomy?

Hematospermia After Prostatectomy: Causes and Evaluation

Hematospermia cannot occur after radical prostatectomy because the seminal vesicles and prostate are removed during this procedure, eliminating the anatomical structures that produce seminal fluid. 1

Anatomical Considerations

Radical prostatectomy involves the complete removal of:

• The prostate gland
• Seminal vesicles
• Part of the vas deferens
• Sometimes adjacent tissues

Without these structures, semen production is not possible after radical prostatectomy. Therefore, patients who have undergone complete prostatectomy should not experience hematospermia, as they no longer produce ejaculate.

Post-Prostatectomy Urological Changes

After radical prostatectomy, patients may experience several urological symptoms, but hematospermia is not among them:

1. Urinary Incontinence

   • Occurs in up to 10-19% of patients at major surgical centers 1
   • Generally improves to near baseline by 12 months after surgery 1
   • Risk factors include advanced age, larger prostate size, and shorter membranous urethral length 1

2. Erectile Dysfunction

   • Highly dependent on patient age, preoperative erectile function, tumor stage, and preservation of neurovascular bundles 1
   • In younger patients (<60 years) with preserved neurovascular bundles, up to 76% may regain full erections 1

3. Climacturia/Sexual Arousal Incontinence

   • Can occur in up to 30% of men following radical prostatectomy 1
   • Main risk factors include time since surgery, prior TURP, and shorter functional urethral length 1

Potential Sources of Confusion

If a patient reports "blood in ejaculate" after prostatectomy, consider these possibilities:

1. Urethral Bleeding

   • Posterior urethral hemangiomas or abnormal varicose vessels can cause bleeding during sexual arousal 2
   • This may be confused with hematospermia but is actually post-ejaculatory hematuria

2. Incomplete Prostatectomy

   • In rare cases where prostate tissue was incompletely removed
   • More common with partial prostatectomy procedures rather than radical prostatectomy

3. Post-Radiation Therapy Bleeding

   • If the patient received radiation therapy rather than surgical prostatectomy
   • Radiation can cause inflammation and bleeding from remaining prostate tissue 1

Diagnostic Approach for Post-Prostatectomy Bleeding During Sexual Activity

If a patient reports "blood in ejaculate" after prostatectomy:

1. Confirm Surgical History

   • Verify that a complete radical prostatectomy was performed
   • Determine if any adjuvant treatments were administered (radiation, etc.)

2. Urological Evaluation

   • Transrectal ultrasound (TRUS) is the first-line imaging tool for evaluation 1
   • MRI pelvis without and with IV contrast if TRUS is negative or inconclusive 1

3. Urethroscopy

   • To identify potential urethral sources of bleeding
   • Particularly important if bleeding occurs during sexual arousal or after orgasm 2

Clinical Pitfalls to Avoid

1. Misdiagnosis

   • Don't assume blood during sexual activity is hematospermia in post-prostatectomy patients
   • Consider urethral or bladder sources of bleeding

2. Overlooking Serious Pathology

   • Persistent bleeding during sexual activity warrants thorough investigation
   • Evaluate for potential urethral hemangiomas, which are treatable with transurethral resection or electrocauterization 2

3. Inadequate Patient Education

   • Patients should understand that true hematospermia is not possible after complete prostatectomy
   • Any bleeding during sexual activity requires proper evaluation

By understanding the anatomical changes following prostatectomy, clinicians can properly evaluate and address bleeding complaints that might be mistakenly reported as "hematospermia" in this patient population.