What is the initial workup for a patient presenting with hematospermia (blood in semen)?

Workup for Hematospermia

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

Initial Clinical Assessment

The baseline workup should include:

• Visual confirmation that blood originates from the patient's ejaculate (not postcoital bleeding from a sexual partner) 1
• Urinalysis 1, 2
• Semen analysis 1
• Complete blood count 1
• Serum chemistry panel 1
• Coagulation studies 1
• Testing for sexually transmitted infections if lower urinary tract symptoms are present 2

Age-Stratified Approach to Further Workup

Men Under 40 Years

No further imaging is needed if:

• Single episode of hematospermia 1
• No risk factors (history of cancer, urogenital malformation, bleeding disorders) 2
• No associated symptoms 1, 2

Proceed with imaging if:

• Persistent or recurrent hematospermia beyond several weeks 1
• Associated symptoms (fever, chills, weight loss, bone pain, lower urinary tract symptoms) 2

The most common identifiable cause in this age group is infection, accounting for approximately 40% of cases overall. 3, 1

Men 40 Years and Older

Mandatory initial workup includes:

• Prostate-specific antigen (PSA) testing even when other causes seem apparent 1
• Digital rectal examination 2
• Transrectal ultrasound (TRUS) as the initial imaging modality 1

TRUS demonstrates abnormalities in 82-95% of men with hematospermia and can identify prostatic calcifications, ejaculatory duct or seminal vesicle cysts, benign prostatic hyperplasia, and Cowper gland masses. 1 It is safe, inexpensive, effective, noninvasive, and radiation-free. 3

Iatrogenic causes from urogenital instrumentation (particularly prostate biopsy) are the most common identifiable cause in this age group. 1, 2

Advanced Imaging

MRI is indicated when:

• TRUS results are negative or inconclusive 1
• Persistent hematospermia despite negative initial workup 3

MRI offers operator-independent imaging, superior soft tissue contrast, and multiplanar high-resolution anatomic evaluation of the prostate gland, seminal vesicles, ejaculatory ducts, and ampullary portions of the vasa deferentia. 3, 1 It can be performed at 1.5 or 3 Tesla, with 3T offering higher signal-to-noise ratio and improved spatial resolution. 3

Key Differential Diagnoses to Consider

Common benign causes:

• Prostatic or ejaculatory duct calcifications 1
• Seminal vesicle or ejaculatory duct cysts 1
• Benign prostatic hyperplasia 1
• Infectious or inflammatory conditions (prostatitis, seminal vesiculitis) 3

Must-not-miss diagnoses:

• Prostate cancer (especially in men ≥40 years) 1
• Internal pudendal artery hemorrhage 1
• Ejaculatory duct obstruction 1

Management Approach

Treatment is directed at the underlying cause once identified:

• Correction of coagulopathy if present 1
• Antibiotics for infectious/inflammatory causes 2
• Urologic referral for persistent cases requiring vesiculoscopy (diagnostic accuracy 74.5% versus 45.3% for TRUS alone) 1

Common Pitfalls

Even with modern imaging techniques, some cases remain idiopathic, but reassurance is appropriate after thorough evaluation excludes serious pathology. 1 The key is distinguishing patients who need aggressive workup (age ≥40, persistent/recurrent symptoms, associated symptoms) from those who can be safely observed (age <40, single episode, no risk factors). 1, 2