Management of Hematospermia with Condyloma-Like Lesions in a 45-Year-Old Male Who Refuses Intervention
Given this patient's age (45 years), transient hematospermia with benign TRUS findings, and his refusal of biopsy/treatment for the condyloma-like lesions, the best course is continued observation with STD test results follow-up, repeat clinical examination in 3-6 months to monitor the penile lesions for any concerning changes (pigmentation, induration, ulceration, or growth), and patient education about warning signs that would necessitate urgent re-evaluation.
Hematospermia Management
Current Status Assessment
Your workup is appropriate and complete for a 45-year-old male. The American College of Radiology recommends TRUS as the initial imaging modality for men ≥40 years with hematospermia, which you performed and found benign prostatic calcifications without concerning features 1.
The hematospermia is likely benign and self-limited. In men 40 years and older, iatrogenic causes from instrumentation are most common, but increased sexual activity (as in this case) can also cause transient bleeding 2. Your TRUS demonstrated no malignancy, obstruction, or significant pathology 1.
Ongoing Hematospermia Monitoring
Reassurance is appropriate given negative imaging findings. Treatment for hematospermia depends on underlying pathology, and when TRUS excludes serious pathology (as in this case), observation is reasonable 1, 3.
Schedule follow-up in 4-6 weeks if hematospermia persists. Recurrent or persistent hematospermia beyond several weeks warrants further investigation, potentially including MRI if TRUS was inconclusive, though your TRUS identified clear findings (calcifications) 1, 4.
Red flags requiring urgent re-evaluation include: fever, chills, weight loss, bone pain, or worsening lower urinary tract symptoms 2, 5.
Condyloma-Like Lesions Management
Risk Stratification Without Biopsy
The patient's refusal of biopsy creates diagnostic uncertainty that must be acknowledged. CDC guidelines state that biopsy is needed when: diagnosis is uncertain, lesions don't respond to therapy, disease worsens, patient is immunocompromised, or warts are pigmented, indurated, fixed, or ulcerated 6.
These "flat brownish" lesions raise concern for potential high-risk HPV or dysplasia. While typical condyloma acuminatum is caused by low-risk HPV types 6 and 11, anogenital condylomata can harbor high-risk genotypes 16 and 18, and may show low-grade dysplasia that can progress to high-grade dysplasia or carcinoma 6.
The brownish pigmentation is a concerning feature. Pigmented lesions are specifically listed as an indication for biopsy in CDC guidelines 6.
Observation Protocol Given Refusal
Since the patient refuses intervention, implement strict surveillance:
Document the lesions thoroughly with photography (with consent) at today's visit to establish baseline appearance, size, distribution, and color for future comparison.
Schedule clinical re-examination in 3 months initially, then every 6 months. At each visit, assess for changes in: size, number, color (especially darkening), texture (induration), fixation to underlying tissue, or ulceration 6.
Any of the following changes mandate urgent biopsy regardless of patient preference: new pigmentation, induration, fixation, ulceration, rapid growth, or bleeding from the lesions 6.
STD Testing Follow-Up
Review all STD results when available. You appropriately ordered comprehensive testing including NAAT for Chlamydia/GC/Trichomonas, HSV serology, HIV, and syphilis 6.
If any STD is positive, treat according to CDC guidelines and re-examine lesions after treatment completion. Sexually transmitted infections are the most common non-iatrogenic cause of hematospermia in sexually active men 2, 3.
Counsel on safer sexual practices and partner notification if STDs are detected 6.
Patient Education and Documentation
Critical Counseling Points
Explicitly document the patient's informed refusal of biopsy and that you explained the risks of missing dysplasia or malignancy, particularly given the pigmented appearance and extensive distribution of lesions.
Provide written instructions listing warning signs: any change in lesion appearance (darkening, thickening, ulceration, bleeding), new lesions, persistent hematospermia beyond 6-8 weeks, or systemic symptoms 6, 2.
Emphasize that while most condylomata are benign, the inability to confirm diagnosis histologically means you cannot definitively rule out dysplasia or early malignancy 6.
Common Pitfall to Avoid
- Do not accept indefinite observation without biopsy if lesions change. The patient's current refusal is acceptable for stable, longstanding lesions, but any evolution in clinical appearance overrides patient preference and requires tissue diagnosis 6.