What is the diagnosis and recommended management for a 27-year-old male with hematospermia (blood in semen) and a 1 cm homogeneous mass in the upper wall of the bladder?

Diagnosis and Management of Bladder Mass with Hematospermia in a 27-Year-Old Male

The 1 cm homogeneous bladder mass with clear edges in a 27-year-old man presenting with hematospermia most likely represents a benign lesion (prostatic utricle cyst, ejaculatory duct cyst, or inflammatory polyp), but requires cystoscopy with biopsy to definitively exclude bladder cancer, followed by transrectal ultrasound to evaluate the seminal vesicles and prostate as the primary source of hematospermia. 1, 2

Differential Diagnosis of the Bladder Mass

The bladder mass characteristics matter significantly:

• A 1 cm homogeneous mass with round clear edges on the upper bladder wall in a young patient is atypical for bladder cancer, which usually presents with irregular borders and heterogeneous appearance 1

• Benign etiologies to consider include:

  • Prostatic utricle cyst (if near bladder neck/trigone)
  • Ejaculatory duct cyst extending into bladder
  • Inflammatory polyp or pseudopolyp
  • Blood clot (though typically less organized) 1, 3

• Bladder cancer remains in the differential despite young age, as 10-20% of bladder cancers can occur in patients under 40 years, though this is uncommon 1

Immediate Next Steps

Cystoscopy with biopsy is mandatory to establish the diagnosis of the bladder mass:

• Rigid or flexible cystoscopy should be performed to directly visualize the lesion, assess its characteristics (pedunculated vs sessile, surface appearance), and obtain tissue diagnosis 1

• Transurethral resection or biopsy of the mass should include the base to ensure adequate sampling for pathologic staging if malignancy is present 1

• Biopsies from the prostatic urethra should be obtained if the tumor is located at the trigone or bladder neck area, as this location raises concern for prostatic urethral involvement 1

Evaluation of the Hematospermia

The hematospermia evaluation should proceed in parallel:

• At age 27 with only 2 weeks of symptoms, hematospermia is typically benign and self-limited in 80-90% of cases, most commonly from infection or inflammation 2, 4

• Transrectal ultrasound (TRUS) should be the initial imaging modality for the seminal tract, as it can identify prostatic calcifications, ejaculatory duct or seminal vesicle cysts, and inflammatory changes with 82-95% sensitivity 1, 2

• TRUS is particularly important here because the bladder mass location (upper wall) suggests the hematospermia may originate from seminal vesicle or ejaculatory duct pathology rather than the bladder itself 1, 3

• MRI should be performed if TRUS is negative or inconclusive, offering superior soft tissue contrast and multiplanar evaluation of the prostate, seminal vesicles, and ejaculatory ducts 1, 2

Additional Workup Required

Complete the baseline evaluation:

• Urinalysis and urine culture to exclude urinary tract infection 2, 4

• Prostate-specific antigen (PSA) testing is not routinely indicated at age 27 unless malignancy is confirmed on biopsy 2, 4

• Coagulation studies (PT/INR, aPTT, platelet count) to exclude bleeding disorders 2

• Sexual history and STI testing if risk factors present, as sexually transmitted infections are common causes of hematospermia in young men 4, 5

Management Algorithm Based on Cystoscopy Findings

If benign pathology confirmed:

• Treat underlying cause (antibiotics for infection, observation for cysts)
• Reassurance that hematospermia typically resolves spontaneously 2, 4
• No further imaging needed if TRUS identifies source of bleeding 1, 2

If bladder cancer confirmed (unlikely but must exclude):

• Stage with CT chest/abdomen/pelvis to assess for metastatic disease 1
• Transurethral resection with complete tumor removal for non-muscle invasive disease 1
• Radical cystectomy consideration for muscle-invasive disease (T2 or higher) 1
• Intravesical BCG therapy for high-grade non-muscle invasive tumors 1

Critical Pitfalls to Avoid

• Do not assume the bladder mass is the source of hematospermia without evaluating the seminal tract with TRUS, as the upper bladder wall location makes this anatomically unlikely 1, 3

• Do not delay cystoscopy despite the patient's young age—any bladder mass requires tissue diagnosis to exclude malignancy 1, 2

• Do not perform only imaging without cystoscopy—CT and ultrasound cannot reliably differentiate benign from malignant bladder lesions 1

• Do not overlook ejaculatory duct obstruction as a cause of both hematospermia and cystic bladder lesions, which TRUS can identify 1, 3