What is the diagnosis and treatment for a 26-year-old male with hematospermia and mild discomfort in the right testis?

Hematospermia in a 26-Year-Old Male

For a 26-year-old otherwise healthy male with hematospermia and mild testicular discomfort, reassurance and watchful waiting are appropriate without imaging, as this represents a benign self-limited condition in the vast majority of cases. 1, 2

Initial Diagnostic Workup

The baseline evaluation should include:

• Visual analysis of the ejaculate to confirm red discoloration and rule out postcoital bleeding from a sexual partner 1, 2
• Urinalysis and urine culture to identify urogenital tract infection, the most common identifiable cause in men under 40 1, 2, 3
• Semen analysis and microbiological testing of the ejaculate 1, 2
• Complete blood count, serum chemistry panel, and coagulation studies to exclude systemic bleeding disorders 1, 2
• Physical examination including digital rectal examination and testicular examination to assess for tenderness, masses, or prostatic abnormalities 3, 4
• Blood pressure measurement to exclude hypertension as a contributing factor 4

When Imaging is NOT Indicated

Imaging is not recommended for your patient because he meets criteria for conservative management: 1, 2

• Age under 40 years
• Transient/episodic hematospermia (not persistent or recurrent)
• Minimal associated symptoms
• No signs of serious disease

The American College of Radiology explicitly states that watchful waiting and reassurance suffice in this population, as hematospermia is typically benign and self-limited. 1, 2

When Further Investigation Would Be Needed

Imaging with transrectal ultrasound (TRUS) as first-line would only be indicated if: 1, 2

• Hematospermia persists beyond several weeks or becomes recurrent
• Associated symptoms develop (fever, chills, weight loss, bone pain, hematuria)
• Patient reaches age 40 or older (requiring prostate-specific antigen screening)

TRUS demonstrates abnormalities in 82-95% of men with hematospermia when indicated, identifying prostatic calcifications, ejaculatory duct cysts, seminal vesicle abnormalities, or prostatitis. 1, 2 MRI is reserved for cases where TRUS is negative or inconclusive. 1, 2

Treatment Approach

Treatment is directed at the underlying cause once identified: 2, 3

• If urogenital infection is detected (most common identifiable cause in men under 40): appropriate antibiotics, antivirals, or antiparasitic agents based on culture results 3, 5
• If coagulopathy is identified: correction of the bleeding disorder 2
• If idiopathic (most common scenario): reassurance alone, as spontaneous resolution typically occurs within several weeks 1, 3, 4

Key Clinical Pitfalls

The mild right testicular discomfort warrants careful testicular examination to exclude epididymitis, orchitis, or testicular pathology, though these would typically present with more pronounced symptoms. 6 However, given the patient's age and presentation, infection remains the most likely etiology if a cause is identified, and empiric antibiotic therapy may be considered if clinical suspicion is high even with negative initial cultures. 3, 5

The most important message for this patient is reassurance that hematospermia in young men is rarely associated with significant pathology and typically resolves spontaneously. 1, 5, 4