What is the appropriate management and treatment for a patient presenting with hematospermia, considering potential underlying conditions such as prostate cancer, prostatitis, or urethral stricture?

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. 1

Age-Stratified Approach to Evaluation

Men Under 40 Years

• Single episode without symptoms: No imaging or extensive workup needed—provide reassurance only 1, 2
• Associated lower urinary tract symptoms: Infection is the most common identifiable cause in this age group 1, 2
  • Perform urinalysis and testing for sexually transmitted infections 2
  • Treat with appropriate antimicrobial therapy if infection identified 3
• Persistent or recurrent hematospermia: Proceed to imaging evaluation despite age 1

Men 40 Years and Older

• Mandatory prostate cancer screening: PSA testing is required even when other causes seem apparent 1
• Most common cause: Iatrogenic from urogenital instrumentation or prostate biopsy 1, 2
• Initial workup includes:
  • Visual confirmation of blood in ejaculate (to exclude partner's postcoital bleeding) 1
  • Digital rectal examination 4
  • PSA testing 2, 4
  • Urinalysis 1, 2
  • Complete blood count, serum chemistry panel, and coagulation studies 1
  • Blood pressure measurement (hypertension is a systemic cause) 4

Imaging Algorithm

First-Line Imaging: Transrectal Ultrasound (TRUS)

• TRUS should be the initial imaging modality for men ≥40 years or any age with persistent/recurrent hematospermia or associated symptoms 1
• Demonstrates abnormalities in 82-95% of men with hematospermia 1
• Can identify:
  • Prostatic calcifications or calculi 1
  • Ejaculatory duct or seminal vesicle cysts 1
  • Benign prostatic hyperplasia 1
  • Cowper gland masses 1
• TRUS-guided aspiration or biopsy can be performed for definitive diagnosis 5

Second-Line Imaging: MRI

• MRI is indicated when TRUS results are negative or inconclusive 5, 1
• MRI pelvis with IV contrast (appropriateness rating 8/9) or without IV contrast (rating 7/9) are both highly appropriate 5
• Dynamic contrast-enhanced MRI should be included for suspected prostate cancer 5
• Advantages include operator-independent imaging, superior soft tissue contrast, and multiplanar high-resolution anatomic evaluation 1

Not Recommended

• CT pelvis has low appropriateness ratings (1-2/9) and delivers significant radiation 5
• Arteriography pelvis has low appropriateness (2/9) and high radiation exposure 5

Red Flags Requiring Thorough Workup

• Persistent or recurrent hematospermia beyond several weeks (regardless of age) 1
• Associated symptoms including:
  • Fever or chills 2
  • Weight loss 2
  • Bone pain 2
  • Hematuria 6
  • Elevated PSA 6

Etiology-Specific Treatment

• Infectious/inflammatory causes (40% of cases overall): Appropriate antiviral, antibiotic, or antiparasitic agents 3
• Coagulopathy: Correct underlying bleeding disorder 1
• Structural abnormalities: May require urologic referral for vesiculoscopy (diagnostic accuracy 74.5% versus 45.3% for TRUS alone) 1
• Malignancy: Definitive treatment of primary lesion 3
• Idiopathic cases: Reassurance after thorough evaluation excludes serious pathology 1

Critical Pitfalls to Avoid

• Do not skip PSA testing in men ≥40 years, even with apparent benign causes 1
• Do not perform extensive imaging in young men (<40) with single episode and no symptoms—this leads to unnecessary anxiety and cost 1, 2
• Urologic malignancy is exceedingly rare: Only 0.05% of benign hematospermia cases are associated with prostate cancer, and only 0.01% in men under 40 6
• Prostatic calcifications are common findings but may not represent the true cause of bleeding 1