What is the cause and treatment of hematospermia in a male of reproductive age with possible urological or reproductive health issues?

Hematospermia: Causes and Management

Blood in semen (hematospermia) is most commonly caused by infection or inflammation in men under 40 years, while in men 40 years and older, iatrogenic causes from urological procedures (especially prostate biopsy) are most frequent, though the majority of cases remain idiopathic and benign. 1

Understanding the Condition

Hematospermia typically occurs in younger men (<40 years) and, while alarming to patients, is usually benign and self-limited. 2 The anxiety it causes is understandable given concerns about malignancy or sexually transmitted infections, but serious pathology is uncommon. 3

Key initial step: Confirm the blood truly originates from the patient's ejaculate rather than postcoital bleeding from a sexual partner—this requires visual confirmation of blood in the ejaculate. 1

Age-Stratified Causes

Men Under 40 Years

• Infectious/inflammatory conditions account for approximately 40% of cases and represent the most common identifiable etiology in this age group 2, 1
• Sexually transmitted infections should be considered when lower urinary tract symptoms are present 3
• Prostatic or ejaculatory duct calcifications (benign) 1
• Seminal vesicle or ejaculatory duct cysts 1

Men 40 Years and Older

• Iatrogenic causes from urogenital instrumentation or prostate biopsy dominate 1, 3
• Benign prostatic hyperplasia 1
• Prostate cancer must not be missed in this age group 1
• Ejaculatory duct obstruction 1
• Vascular malformations (internal pudendal artery hemorrhage) 1

Diagnostic Approach

Men <40 Years with Transient, Single Episode, No Symptoms

Watchful waiting with reassurance is appropriate—no imaging is needed. 2, 1 This represents a benign, self-limited condition in the vast majority of cases.

Basic workup only:

• Visual confirmation of blood in ejaculate 1
• Urinalysis 1, 3
• Testing for sexually transmitted infections if risk factors present 3
• Blood pressure measurement 4

The American College of Radiology rates transrectal ultrasound and MRI as "usually not appropriate" (rating 3) for this scenario. 2

Men ≥40 Years OR Persistent/Recurrent Hematospermia OR Associated Symptoms

These patients require thorough evaluation regardless of age. 1

Initial Laboratory Workup:

• Urinalysis 1
• Semen analysis 1
• Complete blood count 1
• Serum chemistry panel 1
• Coagulation studies 1
• PSA testing is mandatory in men ≥40 years, even when other causes seem apparent 1

Imaging Algorithm:

Step 1: Transrectal Ultrasound (TRUS)

• TRUS should be the initial imaging modality (rated 8/9 "usually appropriate" by ACR) 2, 1
• Identifies abnormalities in 82-95% of men with hematospermia 1
• Can detect prostatic calcifications, ejaculatory duct or seminal vesicle cysts, benign prostatic hyperplasia, and Cowper gland masses 1
• Safe, inexpensive, radiation-free 2

Step 2: MRI if TRUS Negative or Inconclusive

• MRI pelvis with and without IV contrast is rated 8/9 "usually appropriate" when TRUS is negative/inconclusive 2
• Should include dynamic contrast-enhanced sequences if prostate cancer is suspected 2
• Provides operator-independent imaging with superior soft tissue contrast and multiplanar high-resolution anatomic evaluation 1
• MRI without contrast alone is also acceptable (rated 7/9) 2

CT scanning is usually not appropriate (rated 1-2/9) for hematospermia evaluation 2

Red Flags Requiring Immediate Further Investigation

Look for these associated symptoms that mandate thorough workup:

• Fever or chills 3
• Weight loss 3
• Bone pain 3
• Persistent or recurrent episodes beyond several weeks 1
• Any symptoms in men ≥40 years 2

Treatment Approach

Treatment is directed at the underlying cause once identified. 1

• Infectious causes: Appropriate antibiotics, antivirals, or antiparasitic agents based on identified pathogen 5
• Coagulopathy: Correction if identified 1
• Malignancy: Definitive treatment of primary lesion 5
• Persistent cases with negative imaging: Urologic referral for vesiculoscopy may be necessary (diagnostic accuracy 74.5% versus 45.3% for TRUS alone) 1

Common Pitfalls to Avoid

• Do not skip PSA testing in men ≥40 years even if another cause seems obvious—prostate cancer must be excluded 1
• Do not assume prostatic calcifications are the cause—they are common findings but may not represent the true etiology 1
• Do not over-investigate young men with single, transient episodes—this leads to unnecessary anxiety and healthcare costs 2, 1
• Do not forget to measure blood pressure—hypertension is a systemic cause that can contribute 4

Reassurance for Idiopathic Cases

Even with modern imaging techniques, some cases remain idiopathic after thorough evaluation. 1 Reassurance remains appropriate after serious pathology has been excluded, as the natural history is typically benign and self-limited. 1, 3