What is the workup for hematospermia?

Workup for Hematospermia

The workup for hematospermia should be stratified based on patient age, persistence of symptoms, and associated risk factors, with transrectal ultrasound (TRUS) being the first-line imaging modality for men ≥40 years or those with persistent hematospermia. 1

Initial Evaluation

For Men <40 Years with Transient/Episodic Hematospermia and No Other Symptoms:

• Detailed history focusing on:
  • Duration and frequency of hematospermia
  • Associated symptoms (pain, fever, weight loss)
  • Sexual history and risk factors for STIs
  • Recent urogenital procedures or trauma
  • Medication use (anticoagulants)
• Physical examination including:
  • Blood pressure assessment
  • Genital examination
  • Digital rectal examination
• Laboratory testing:
  • Visual analysis of ejaculate
  • Urinalysis and urine culture
  • Microbiological testing for STIs
  • Semen analysis
  • Complete blood count
  • Coagulation profile
  • Serum chemistry panel 1, 2

Important: In this population, imaging is generally not recommended as hematospermia is typically benign and self-limiting. Watchful waiting and reassurance are usually sufficient. 1

For Men ≥40 Years OR Any Man with Persistent Hematospermia OR Associated Symptoms:

Laboratory Testing (in addition to above):

• Prostate-specific antigen (PSA) testing 1, 2

Imaging Studies (in order of preference):

1. Transrectal Ultrasound (TRUS) - Rated 8/9 for appropriateness 1

   • First-line imaging modality
   • Can detect:
     • Prostatic calcifications/calculi
     • Seminal vesicle abnormalities
     • Ejaculatory duct obstruction/cysts
     • Prostatitis
     • Prostatic masses

2. MRI of Pelvis - Rated 7-8/9 for appropriateness 1

   • Indicated if TRUS is negative or inconclusive
   • Without IV contrast (rating: 7/9)
   • With and without IV contrast (rating: 8/9) - preferred for suspected prostate cancer
   • Superior for evaluating:
     • Seminal vesicle hemorrhage
     • Ejaculatory duct abnormalities
     • Prostatic masses
     • Vascular malformations

3. CT Pelvis with IV contrast - Rated 2/9 for appropriateness 1

   • Limited utility due to poor soft tissue contrast
   • Can identify calcifications, gross masses, or cystic lesions

4. Pelvic Angiography - Rated 2/9 for appropriateness 1

   • Reserved for intractable hematospermia when other evaluations are negative
   • Can identify and potentially treat arterial sources of bleeding

Special Considerations

Persistent or Recurrent Hematospermia:

• More extensive evaluation is warranted
• Consider referral to urology for:
  • Cystourethroscopy
  • Transurethral seminal vesiculoscopy (if available)
  • Seminal vesicle aspiration under TRUS guidance 1, 3

Associated Symptoms Requiring More Urgent Evaluation:

• Fever, chills (infection)
• Weight loss (malignancy)
• Bone pain (metastatic disease)
• Hematuria (urological malignancy)
• Lower urinary tract symptoms (infection, obstruction) 2, 4

Common Pitfalls to Avoid

1. Overlooking age as a risk factor

   • Men ≥40 years require more thorough evaluation even with single episode 1, 2

2. Missing iatrogenic causes

   • Recent prostate biopsy is the most common cause in older men
   • Can persist for 4-6 weeks post-procedure 2

3. Inadequate STI screening

   • Infections are the most common cause in younger men 1, 4

4. Excessive imaging in low-risk patients

   • Young men (<40) with single episode and no symptoms rarely need imaging 1, 2

5. Failure to reassure appropriately

   • Hematospermia causes significant anxiety but is usually benign
   • Clear communication about benign nature is essential for quality of life 3

By following this structured approach to the workup of hematospermia, clinicians can appropriately identify those patients who require more extensive evaluation while avoiding unnecessary testing in those with benign, self-limiting conditions.