What are the evaluation and treatment options for hematospermia (blood in semen)?

Evaluation and Treatment of Hematospermia

For men under 40 years with a single episode of hematospermia and no associated symptoms, reassurance and watchful waiting without imaging is the appropriate management, as this represents a benign self-limited condition in the vast majority of cases. 1

Age-Based Risk Stratification

The approach to hematospermia fundamentally depends on patient age, as the underlying etiologies differ significantly:

Men Under 40 Years

• Infection is the most common identifiable cause in this age group, particularly sexually transmitted infections and other urogenital infections 1, 2
• Single episode without symptoms requires only reassurance—no imaging or extensive workup is needed 1, 2
• If lower urinary tract symptoms are present, limit workup to urinalysis and STI testing, treating as indicated 2

Men 40 Years and Older

• Iatrogenic causes from urogenital instrumentation dominate in this age group, though most cases remain idiopathic 1, 2
• PSA testing is mandatory even when other causes seem apparent, as prostate cancer must not be missed 1
• More aggressive evaluation is warranted given higher malignancy risk 2, 3

Initial Evaluation Algorithm

Step 1: Confirm True Hematospermia

• Visual confirmation that blood originates from the patient's ejaculate rather than postcoital bleeding from a sexual partner 1

Step 2: Baseline Laboratory Workup

The American College of Radiology recommends the following baseline studies 1:

• Visual analysis of ejaculate
• Urinalysis
• Semen analysis
• Complete blood count
• Serum chemistry panel
• Coagulation studies

Step 3: Physical Examination Essentials

• Blood pressure measurement to identify hypertension 4
• Abdominal palpation for hepatosplenomegaly or renal enlargement 4
• Genital examination for testicular masses and urethral discharge 4
• Digital rectal examination to assess prostate 2, 4

Red Flags Requiring Further Investigation

Any of the following warrant thorough workup regardless of age 1, 2:

• Persistent or recurrent hematospermia beyond several weeks
• Associated symptoms: fever, chills, weight loss, bone pain
• History of cancer
• Known urogenital malformation
• Bleeding disorders

Imaging Strategy

First-Line Imaging: Transrectal Ultrasound (TRUS)

TRUS should be the initial imaging modality for men ≥40 years or any age with persistent/recurrent hematospermia or associated symptoms, demonstrating abnormalities in 82-95% of men with hematospermia 1

TRUS can identify 1:

• Prostatic calcifications (common benign finding)
• Ejaculatory duct or seminal vesicle cysts
• Benign prostatic hyperplasia
• Cowper gland masses

Second-Line Imaging: MRI

MRI is indicated when TRUS results are negative or inconclusive, with advantages including operator-independent imaging, superior soft tissue contrast, and multiplanar high-resolution anatomic evaluation 1, 5

Common Etiologies by Category

Benign Structural Causes

• Prostatic or ejaculatory duct calcifications (most common benign cause) 1
• Seminal vesicle or ejaculatory duct cysts 1
• Benign prostatic hyperplasia 1
• Ejaculatory duct obstruction 1
• Seminal vesicle dilatation (width >1.7 cm) 1

Infectious/Inflammatory

• Most common in men under 40 years 1, 2
• Treat with appropriate antiviral, antibiotic, or antiparasitic agents 3

Neoplastic (Must Not Miss)

• Prostate cancer is the critical diagnosis to exclude in men ≥40 years 1
• Testicular and seminal vesicle cancers are rare causes 3

Vascular

• Internal pudendal artery hemorrhage 1
• Prostatic varices 4

Treatment Approach

Treatment is directed at the underlying cause once identified 1:

• Correct coagulopathy if present 1
• Appropriate antimicrobial therapy for infections 3
• Urologic referral for persistent cases requiring vesiculoscopy (diagnostic accuracy 74.5% versus 45.3% for TRUS alone) 1
• Definitive treatment of malignant lesions 3

Critical Pitfalls to Avoid

• Do not skip PSA testing in men ≥40 years, even when another cause seems obvious 1
• Do not assume prostatic calcifications are the true cause—they are common findings that may be incidental 1
• Do not dismiss recurrent episodes in younger men—persistent symptoms beyond several weeks require full workup regardless of age 1
• Even with modern imaging, some cases remain idiopathic, but reassurance is appropriate only after thorough evaluation excludes serious pathology 1