What is the appropriate evaluation and treatment for a patient with hematospermia (blood in semen), mild dysuria (burning following ejaculation), and a clean urinalysis, who has not had recent sexually transmitted infection (STI) testing and has a single sexual partner?

Evaluation and Management of Hematospermia in a Young Patient

For this patient under 40 years old with hematospermia and mild post-ejaculatory burning, the appropriate approach is STI testing (including gonorrhea and chlamydia), urinalysis with culture, and reassurance, as infection is the most common identifiable cause in this age group and the condition is typically benign and self-limited. 1, 2

Initial Evaluation

The first step is confirming true hematospermia versus postcoital bleeding from the sexual partner by visual confirmation of blood throughout the ejaculate, which this patient has already established (pink/red throughout). 1, 2

Essential Laboratory Testing

• STI testing is mandatory given the lack of recent testing, single sexual partner status, and associated mild dysuria (burning following ejaculation), as urogenital infections are the most common identifiable cause in men under 40. 1, 2, 3
• Urine culture should be obtained despite the clean urinalysis, as infection remains the primary concern even with negative dipstick. 1, 2
• Semen analysis with microbiological testing can identify infection not detected by urinalysis alone. 1
• Complete blood count and coagulation studies should be considered to exclude systemic bleeding disorders, though less likely given isolated hematospermia. 1, 2

Physical Examination Priorities

• Digital rectal examination to assess for prostatic tenderness (prostatitis), masses, or nodules. 1, 3
• Blood pressure measurement to exclude hypertension as a contributing vascular factor. 4
• Genital examination for urethral discharge, testicular masses, or epididymal tenderness. 3, 5

Management Based on Age and Duration

For This Patient (Under 40, First Episode, 4 Days Duration)

Watchful waiting with reassurance is appropriate after initial testing, as hematospermia in men under 40 without risk factors is benign and self-limited in 80-90% of cases. 1, 2, 3 The mild burning suggests possible infection, making empiric treatment reasonable while awaiting culture results.

When Imaging Is NOT Indicated

• No imaging is needed for transient hematospermia in men under 40 with no associated symptoms beyond mild dysuria. 1, 2, 3
• The American College of Radiology explicitly recommends watchful waiting and reassurance without imaging for this demographic. 1, 2

When Further Evaluation IS Required

Proceed to imaging if any of the following develop:

• Persistent hematospermia beyond several weeks despite treatment. 1, 2
• Recurrent episodes after initial resolution. 1, 3, 6
• Associated systemic symptoms including fever, chills, weight loss, or bone pain. 3, 4
• Associated hematuria (not present in this case). 7, 6
• Palpable masses or nodules on physical examination. 3, 5

Treatment Approach

Empiric Treatment While Awaiting Results

If STI testing is pending and clinical suspicion for infection is high (given the dysuria), consider empiric treatment with:

• Antibiotics covering common urogenital pathogens (e.g., doxycycline for chlamydia, ceftriaxone for gonorrhea). 3, 5
• Treatment should be adjusted based on culture results and partner notification/treatment if STI confirmed. 3

Reassurance Strategy

Explicitly address patient anxiety by explaining that:

• Hematospermia is rarely associated with malignancy in men under 40. 1, 2, 3
• Most cases resolve spontaneously within weeks. 2, 3, 6
• The presence of mild dysuria actually suggests a treatable infectious cause rather than serious pathology. 3, 5

Common Pitfalls to Avoid

• Do not order imaging (TRUS or MRI) for first-episode hematospermia in men under 40 unless persistent or associated with concerning features, as this represents overutilization. 1, 2
• Do not skip STI testing even with a single partner, as asymptomatic carriage is common. 3
• Do not assume clean urinalysis excludes infection—urine culture and semen analysis provide additional diagnostic yield. 1, 2
• Do not forget to distinguish from partner's postcoital bleeding, though this patient has already confirmed blood throughout ejaculate. 1, 2

Follow-Up Plan

• Reassess in 2-4 weeks after completing any prescribed antibiotics. 3, 6
• If symptoms persist beyond 4-6 weeks, proceed to transrectal ultrasound (TRUS) as first-line imaging, which demonstrates abnormalities in 82-95% of cases. 1, 2, 8
• If TRUS is negative or inconclusive, MRI provides superior soft tissue evaluation of the seminal tract. 1, 2, 8