What is the appropriate evaluation and management for a patient with hematospermia?

Evaluation and Management of 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; however, men 40 years and older require prostate cancer screening with PSA testing and transrectal ultrasound (TRUS) as initial imaging, regardless of whether other causes seem apparent. 1

Age-Stratified Approach to Evaluation

Men Under 40 Years

• Single episode without symptoms: Provide reassurance and observe without imaging, as infection is the most common identifiable cause in this age group and most cases resolve spontaneously 1, 2
• Persistent or recurrent episodes: Proceed with full workup as outlined below 1
• Confirm true hematospermia by visual analysis of ejaculate to exclude postcoital bleeding from a sexual partner 1

Men 40 Years and Older

• Mandatory evaluation even for single episodes, as iatrogenic causes from urogenital instrumentation dominate and prostate cancer risk increases 1
• Prostate cancer screening with PSA testing is required even when other causes seem apparent 1
• TRUS should be the initial imaging modality, demonstrating abnormalities in 82-95% of men with hematospermia 1

Initial Workup Components

The baseline evaluation should include 1:

• Visual confirmation of blood in ejaculate (not partner bleeding)
• Urinalysis
• Semen analysis
• Complete blood count
• Serum chemistry panel
• Coagulation studies
• PSA testing (for men ≥40 years)

Physical Examination Priorities

Focus on specific findings rather than generic examination 3:

• Blood pressure measurement to identify hypertension as a systemic cause 3
• Genital examination for testicular masses and urethral discharge 4
• Digital rectal examination to assess prostate size, nodules, and tenderness 4
• Abdominal palpation for hepatosplenomegaly or renal enlargement 4

Imaging Algorithm

First-Line: Transrectal Ultrasound (TRUS)

• Indicated for: Men ≥40 years, any age with persistent/recurrent hematospermia, or associated symptoms 1
• TRUS identifies prostatic calcifications (most common benign finding), ejaculatory duct or seminal vesicle cysts, benign prostatic hyperplasia, and Cowper gland masses 1
• Note that prostatic calcifications are common but may not represent the true cause 1

Second-Line: MRI

• Indicated when: TRUS results are negative or inconclusive 1
• Advantages include operator-independent imaging, superior soft tissue contrast, and multiplanar high-resolution anatomic evaluation 1

Common Etiologies by Age

Under 40 Years

• Infection (most common identifiable cause) 1, 2
• Prostatic or ejaculatory duct calcifications 1
• Seminal vesicle or ejaculatory duct cysts 1

40 Years and Older

• Iatrogenic from urogenital instrumentation (most common) 1
• Benign prostatic hyperplasia 1
• Prostate cancer (must not be missed) 1
• Ejaculatory duct obstruction 1
• Internal pudendal artery hemorrhage (vascular cause) 1

Management Strategy

• Treat the underlying cause once identified 1
• Correct any coagulopathy if identified 1
• For persistent cases with negative imaging, urologic referral for vesiculoscopy may be necessary (diagnostic accuracy 74.5% versus 45.3% for TRUS alone) 1
• Even with modern imaging, some cases remain idiopathic, but reassurance is appropriate after thorough evaluation excludes serious pathology 1

Critical Pitfalls to Avoid

• Do not skip PSA testing in men ≥40 years even when benign causes like calcifications are identified on imaging 1
• Do not assume partner bleeding without visual confirmation of blood in the patient's ejaculate 1
• Do not provide false reassurance to men over 40 without proper workup, as the association with serious pathology increases with age 2
• Persistent or recurrent hematospermia beyond several weeks requires thorough workup regardless of age 1