What is the diagnosis, evaluation, and management of hematospermia?

Diagnosis, Evaluation, and Management of Hematospermia

For men under 40 years with transient hematospermia and no associated symptoms, watchful waiting with reassurance is appropriate without imaging, as this represents a benign self-limited condition in the vast majority of cases. 1

Initial Approach for All Patients

The evaluation begins with determining whether blood truly originates from the patient's ejaculate versus postcoital bleeding from a sexual partner. 1

Essential baseline workup includes: 1

• Visual analysis of ejaculate for red discoloration
• Urinalysis and urine culture
• Microbiological testing for sexually transmitted infections
• Semen analysis
• Complete blood count
• Serum chemistry panel
• Coagulation studies

Physical examination must assess: 1

• Blood pressure measurement (to identify hypertension as a systemic cause) 2
• Digital rectal examination of the prostate
• Testicular examination for masses
• Assessment for urethral discharge 3

Age-Based and Symptom-Based Algorithm

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

Imaging is NOT recommended for this population. 1 The condition is typically benign, self-limiting, and most commonly caused by urogenital infections (approximately 40% of cases). 1

Management consists of: 1

• Patient reassurance
• Watchful waiting
• Routine clinical evaluation only
• Treatment of identified infections if present 4

Common pitfall: Ordering extensive imaging in young men with single episodes creates unnecessary anxiety and cost without improving outcomes, as the condition resolves spontaneously in most cases. 1, 4

Men ≥40 Years OR Any Age with Persistent/Recurrent Hematospermia OR Associated Symptoms

All patients in this category require prostate-specific antigen (PSA) testing to screen for prostate cancer. 1

Associated symptoms warranting further investigation include: 4, 2

• Fever or chills
• Weight loss
• Bone pain
• Lower urinary tract symptoms
• Hematuria

First-Line Imaging: Transrectal Ultrasound (TRUS)

TRUS should be the initial imaging modality, demonstrating abnormalities in 82-95% of men with hematospermia. 1

TRUS can identify: 1

• Prostatic calcifications or calculi
• Ejaculatory duct or seminal vesicle calculi
• Prostatic, ejaculatory duct, or seminal vesicle cysts
• Benign prostatic hyperplasia
• Prostatitis
• Cowper gland masses

Important caveat: Some TRUS findings (benign prostatic hyperplasia, prostatic calcifications, nonobstructing cysts) are age-related changes found in asymptomatic patients and may not be the actual cause of hematospermia. 1

TRUS can also guide therapeutic interventions: 1

• Transperineal aspiration of seminal vesicles
• Drainage of cysts or abscesses
• Prostate biopsy if cancer is suspected

Second-Line Imaging: MRI

MRI is indicated when TRUS results are negative or inconclusive. 1

MRI advantages over TRUS: 1

• Operator-independent
• Superior soft tissue contrast
• Multiplanar high-resolution anatomic evaluation
• Can be performed at 1.5T or 3T (3T offers higher signal-to-noise ratio)

MRI protocol should include: 1

• Small field-of-view axial T1-weighted images
• Axial, sagittal, and coronal T2-weighted images of prostate, seminal vesicles, ejaculatory ducts, and ampullary vasa deferentia
• Large field-of-view images for pelvic lymphadenopathy
• Dynamic contrast-enhanced sequences if prostate cancer is suspected 1

Third-Line Imaging: CT and Angiography

CT has limited value due to poor soft tissue contrast and inability to differentiate structural changes adequately. 1

Pelvic angiography is reserved exclusively for intractable hematospermia (with or without hematuria) when all clinical, laboratory, and noninvasive imaging have failed to identify an etiology. 1 If an arterial source (such as internal pudendal artery) is identified, transcatheter arterial embolization can be performed therapeutically in the same session. 1

Common Etiologies by Age

In men <40 years: 1, 4

• Infectious/inflammatory conditions (most common identifiable cause)
• Sexually transmitted infections
• Prostatitis or seminal vesiculitis
• Iatrogenic (post-prostate biopsy)

In men ≥40 years: 4, 5

• Iatrogenic from urogenital instrumentation or prostate biopsy (most common)
• Ejaculatory duct obstruction or stricture at verumontanum
• Prostatic calculi
• Vascular malformations
• Prostate cancer (must be excluded)
• Systemic disorders increasing bleeding risk

Management Based on Etiology

Treatment is directed at the underlying cause once identified: 2

• Antibiotics for infectious/inflammatory causes
• Drainage of cysts or abscesses (can be TRUS-guided) 3
• Management of hypertension if present 2
• Correction of coagulopathy if identified
• Urologic referral for persistent cases requiring vesiculoscopy (diagnostic accuracy 74.5% versus 45.3% for TRUS alone) 1

Key principle: Even with modern imaging, some cases remain idiopathic, but the number has decreased significantly with improved diagnostic techniques. 1, 5 In these cases, reassurance remains appropriate after thorough evaluation excludes serious pathology.