Workup for Hematospermia in Men Above Age 40
Men ≥40 years with hematospermia require prostate cancer screening with PSA testing, detailed clinical evaluation with laboratory workup, and transrectal ultrasound (TRUS) as first-line imaging, with MRI reserved for negative or inconclusive TRUS results. 1
Initial Clinical Assessment
The workup begins with confirming true hematospermia versus postcoital bleeding from a sexual partner through visual confirmation of blood in the ejaculate. 2 Key historical elements include:
- Duration and frequency of episodes (transient vs. persistent/recurrent) 1
- Associated symptoms: fever, chills, weight loss, bone pain, lower urinary tract symptoms 3, 4
- Recent urogenital instrumentation (most common iatrogenic cause in this age group) 2, 3
- Bleeding disorders or anticoagulation use 3, 4
- History of cancer or urogenital malformations 3
- Blood pressure measurement to assess for hypertension as a systemic cause 4
Mandatory Laboratory Evaluation
All men ≥40 years require the following baseline workup:
- Prostate-specific antigen (PSA) testing for prostate cancer screening (mandatory even when other causes seem apparent) 1, 2
- Visual analysis of ejaculate for red discoloration 1
- Urinalysis and urine culture 1, 2
- Semen analysis and microbiological testing 1
- Complete blood count 2
- Serum chemistry panel 2
- Coagulation studies 2
Imaging Algorithm
First-Line: Transrectal Ultrasound (TRUS)
TRUS should be the initial imaging modality, demonstrating abnormalities in 82-95% of men with hematospermia. 1, 2 TRUS can identify:
- Prostatic, ejaculatory duct, or seminal vesicle calcifications/calculi 1
- Seminal vesicle, ejaculatory duct, or prostatic cysts 1
- Benign prostatic hyperplasia 1
- Prostatitis 1
- Cowper gland masses 1, 2
- Seminal vesicle dilatation (width >1.7 cm) 2
Important caveat: Some TRUS findings (prostatic calcifications, benign prostatic hyperplasia, nonobstructing prostatic cysts) are age-related changes found in asymptomatic patients and may not represent the true cause of hematospermia. 1
Second-Line: MRI
MRI is indicated when TRUS results are negative or inconclusive. 1 MRI provides superior advantages:
- Operator-independent imaging with superior soft-tissue contrast 2
- Multiplanar high-resolution anatomic evaluation of prostate, seminal vesicles, ampulla of vas deferens, and ejaculatory ducts 1
- Better determination of the organ of origin for midline/paramedian prostatic cysts 1
- More accurate assessment of ejaculatory duct obstruction and location/age of hemorrhage within the seminal tract compared to TRUS 1
Critical note: MRI has no established role in screening for prostate cancer; its utility is solely for demonstrating anatomic abnormalities that may account for hematospermia. 1
Additional Diagnostic Modalities
For persistent/refractory cases where noninvasive imaging is unrevealing:
- Transurethral seminal vesiculoscopy has 74.5% diagnostic accuracy versus 45.3% for TRUS alone, with combined modalities yielding highest accuracy 1, 2
- Vesiculoscopy is most useful for detecting calculi and obstruction/stricture at the verumontanum orifice or ejaculatory duct 1
- Angiography is reserved for intractable hematospermia with or without hematuria when all other evaluations are unrevealing, allowing identification and transcatheter embolization of arterial hemorrhage sources (e.g., internal pudendal artery) 1
Common Pitfalls to Avoid
- Do not skip PSA testing even when benign causes are identified on imaging, as prostate cancer must not be missed in this age group 1, 2
- Do not over-interpret age-related TRUS findings (prostatic calcifications, BPH) as definitive causes without clinical correlation 1
- Do not order MRI for prostate cancer screening—its role is limited to anatomic evaluation of the ejaculatory tract 1
- Persistent or recurrent hematospermia beyond several weeks requires thorough workup regardless of initial reassuring findings 2
Management Approach
Treatment is directed at the underlying cause once identified: