Hematospermia: Causes and Management
Direct Recommendation
For men under 40 years with a single episode of hematospermia and no associated symptoms, reassurance and watchful waiting is appropriate without imaging, as this represents a benign self-limited condition in the vast majority of cases. 1, 2
Age-Based Algorithmic Approach
Men <40 Years Old with Transient/Single Episode
No imaging is required if the patient has no associated symptoms (fever, weight loss, bone pain, lower urinary tract symptoms) and no risk factors (cancer history, bleeding disorders, urogenital malformations). 1, 2, 3
Initial workup should include:
When infection is the most common cause in this age group (approximately 40% of cases), treatment should target identified pathogens. 1, 4, 5
Men ≥40 Years OR Any Age with Persistent/Recurrent Hematospermia
All men ≥40 years require prostate-specific antigen (PSA) screening to evaluate for prostate cancer. 1, 2
Transrectal ultrasound (TRUS) should be the first-line imaging modality, demonstrating abnormalities in 82-95% of men with hematospermia. 1, 2
- TRUS identifies: prostatic calcifications/calculi, ejaculatory duct or seminal vesicle cysts, benign prostatic hyperplasia, prostatitis, and Cowper gland masses 1, 2
- Important caveat: Some TRUS findings (prostatic calcifications, benign prostatic hyperplasia, nonobstructing cysts) are age-related changes found in asymptomatic patients and may not be causative. 1
MRI pelvis (with or without contrast) is indicated when TRUS is negative or inconclusive. 1, 2
- MRI provides superior soft tissue contrast, multiplanar imaging, and operator-independent evaluation 1, 2
- MRI better characterizes ejaculatory duct obstruction, determines origin of midline/paramedian prostatic cysts, and identifies location and age of hemorrhage within the seminal tract 1
- Seminal vesicle width >1.7 cm suggests pathology 1
Common Etiologies by Clinical Context
Iatrogenic (Most Common in Men ≥40)
Infectious/Inflammatory (Most Common in Men <40)
- Prostatitis, seminal vesiculitis, urethritis, or sexually transmitted infections account for ~40% of all cases. 1, 4, 5
Structural Abnormalities
Systemic Causes
- Uncontrolled hypertension, coagulopathy, anticoagulant use, or hematologic disorders require blood pressure measurement and coagulation assessment. 1, 5
Red Flags Requiring Immediate Further Investigation
- Associated symptoms: Fever, chills, weight loss, bone pain, lower urinary tract symptoms 3, 5
- Persistent or recurrent episodes despite initial management 1, 2
- Age ≥40 years (higher malignancy risk) 1, 3
- Abnormal PSA or prostate examination 1, 3
Advanced Diagnostic Modalities
Transurethral seminal vesiculoscopy has 74.5% diagnostic accuracy (versus 45.3% for TRUS alone) and is most useful for detecting calculi and ejaculatory duct obstruction/stricture. 1, 2
TRUS-guided aspiration of seminal vesicles can confirm ejaculatory duct obstruction or provide definitive diagnosis of cystic lesions. 1
CT pelvis and arteriography are NOT appropriate (rated 1-2 on ACR appropriateness scale) and expose patients to unnecessary radiation. 1
Treatment Strategy
Treatment is directed at the underlying cause once identified: 2
Reassurance remains appropriate even when imaging reveals no definitive cause, as many cases remain idiopathic despite modern imaging. 1, 2
Critical Pitfalls to Avoid
Do not routinely image young men (<40) with single episodes – this leads to unnecessary anxiety, cost, and potential overdiagnosis of incidental findings. 1, 2
Do not skip PSA testing in men ≥40 – prostate cancer must be excluded in this population. 1, 2
Do not assume TRUS findings are causative – age-related changes like prostatic calcifications are common in asymptomatic men. 1
Do not use MRI to screen for prostate cancer – MRI's role is anatomic evaluation of the seminal tract, not cancer screening. 1