Persistent Penile Bleeding for 13 Years
You need urgent urologic evaluation with urethroscopy to identify and treat the source of bleeding, most likely urethral varicosity or vascular malformation, which can be definitively managed with endoscopic cauterization or embolization.
Immediate Assessment Required
This 13-year pattern of penile bleeding requires systematic investigation to identify the anatomic source:
- Determine the precise timing of bleeding - whether it occurs during penile erection, immediately after ejaculation, or independent of sexual activity, as this localizes the pathology 1
- Assess for pain - painless bleeding during erection or sexual activity strongly suggests urethral varicosity or vascular malformation rather than traumatic injury 2, 1
- Document bleeding characteristics - frank blood from the urethral meatus versus blood mixed with urine or semen helps differentiate urethral from bladder or seminal tract sources 1
Most Likely Diagnosis
Given the 13-year duration and apparent recurrent nature:
- Posterior urethral varicosity is the most common cause of sexual activity-related hematuria, particularly bleeding during penile erection or immediately post-ejaculation 1
- Urethral vascular malformations (as seen in conditions like Klippel-Trenaunay syndrome) can cause painless urethral bleeding during erection 2
- Seminal vesicle pathology should be considered if bleeding occurs specifically with ejaculation and may be accompanied by hemospermia 1
Diagnostic Workup
Urethroscopy is the gold standard diagnostic and therapeutic procedure for identifying the bleeding source 1:
- Direct visualization identifies posterior urethral varicosity in the majority of cases with sexual activity-related bleeding 1
- Allows simultaneous treatment with cauterization using electric excision ring or holmium laser 1
- If urethroscopy is negative or hemospermia is present, seminal tract endoscopy should be performed to evaluate for seminal vesicle bleeding 1
Imaging studies have limited utility for this specific presentation:
- Pelvic angiography is reserved for intractable bleeding when non-invasive evaluation fails to identify a source 3
- Color duplex ultrasonography can identify vascular malformations but does not replace direct endoscopic visualization 2
Definitive Treatment
Endoscopic cauterization provides excellent outcomes with minimal complications:
- In a series of 12 patients with sexual activity-related hematuria treated with urethroscopic cauterization, 11 (92%) had complete resolution of bleeding with no recurrence during 3-45 months follow-up 1
- No complications including urethral stricture, epididymitis, or erectile dysfunction were observed 1
- One patient experienced two isolated episodes of post-ejaculation bleeding at 2 and 10 months but no further recurrence 1
For refractory cases or identified arterial bleeding sources:
- Selective arterial embolization with microcoils can be performed for pudendal artery hemorrhage 4
- Bilateral internal pudendal artery embolization does not cause erectile dysfunction when performed with accurate super-selective technique that preserves collateral circulation 4
- Embolization is particularly indicated when angiography demonstrates active extravasation from the internal pudendal artery 4
Critical Clinical Pitfalls
Do not delay urologic referral - 13 years of bleeding suggests this has been managed conservatively or dismissed, but definitive diagnosis and treatment are readily available 1
Do not assume this is benign hematuria requiring only observation - while not immediately life-threatening, the persistent nature warrants investigation to exclude other pathology and provide definitive treatment 1
Do not confuse this with priapism or penile fracture - these are distinct urologic emergencies with different presentations (prolonged painful erection or acute trauma with immediate detumescence) 5, 6
Ensure complete evaluation - if initial urethroscopy is negative, proceed to seminal tract endoscopy rather than abandoning the diagnostic workup 1