What is the recommended evaluation and treatment for recurrent hematospermia (blood in semen) after two episodes in two weeks?

Recurrent Hematospermia: Two Episodes in Two Weeks

For recurrent hematospermia (two episodes within two weeks), the appropriate management depends critically on age: men under 40 without associated symptoms can be reassured with watchful waiting and no imaging, while men ≥40 years or those with associated symptoms require transrectal ultrasound (TRUS) as the initial imaging study. 1, 2

Age-Based Risk Stratification

The two-week recurrence pattern you describe qualifies as "episodic" rather than truly persistent hematospermia, which changes the evaluation approach based on patient age:

Men Under 40 Years Without Associated Symptoms

• No imaging is recommended - the ACR Appropriateness Criteria rates all imaging modalities (TRUS, MRI, CT) as "usually not appropriate" (rating 3 or below) for this population 1
• This represents a benign, self-limited condition in the vast majority of young men, with infection being the most common etiology 3, 4
• Reassurance is the primary intervention after basic evaluation excludes serious pathology 2, 5

Men ≥40 Years or Any Age With Associated Symptoms

• TRUS is the first-line imaging study with an appropriateness rating of 8 ("usually appropriate") 1
• TRUS demonstrates abnormalities in 82-95% of men with hematospermia and can identify prostatic calcifications, ejaculatory duct cysts, seminal vesicle cysts, benign prostatic hyperplasia, and Cowper gland masses 2
• MRI pelvis (with or without contrast) is indicated if TRUS is negative or inconclusive, also rated 7-8 for appropriateness, particularly useful for evaluating suspected prostate cancer or ejaculatory duct obstruction 1, 2

Essential Initial Workup

Before any imaging decisions, complete the following baseline evaluation:

• Confirm blood originates from ejaculate versus postcoital bleeding from sexual partner 2
• Visual analysis of ejaculate 2
• Urinalysis and semen analysis 2, 4
• Complete blood count, serum chemistry panel, and coagulation studies to identify bleeding disorders 2
• Digital rectal examination and blood pressure measurement to assess for prostatic pathology and hypertension 4, 5
• Screen for sexually transmitted infections in appropriate clinical contexts 5

Red Flags Requiring Urologic Evaluation

Regardless of age, the following warrant more aggressive workup:

• Associated symptoms: fever, pain, weight loss, dysuria, or urinary obstruction 6, 7, 4
• Risk factors: history of cancer, urogenital malformations, bleeding disorders, or anticoagulation therapy 6
• Truly persistent hematospermia (continuous rather than episodic over weeks to months) 3, 7
• Refractory cases not responding to conservative management 7, 4

Common Pitfalls to Avoid

• Don't over-image young men with isolated episodic hematospermia - this creates unnecessary anxiety and healthcare costs without improving outcomes 1
• Don't dismiss recurrent episodes in men ≥40 - malignancy risk increases with age and must be excluded 3, 4, 5
• Don't skip coagulation studies - systemic bleeding disorders and hypertension are underrecognized causes 2, 4
• Don't order CT scans - they are rated as "usually not appropriate" (rating 1-2) for hematospermia evaluation due to radiation exposure without diagnostic advantage 1

Treatment Approach

• Treatment targets the underlying cause once identified through evaluation 2, 7
• Correct any coagulopathy if laboratory studies reveal bleeding disorders 2
• Urologic referral for vesiculoscopy may be necessary in persistent cases, with diagnostic accuracy of 74.5% versus 45.3% for TRUS alone 2
• Reassurance remains appropriate even when imaging is negative after thorough evaluation excludes serious pathology 2, 5