What is the diagnosis and treatment for a adult male with hematospermia and right testicular pain?

Diagnosis and Management of Hematospermia with Testicular Pain

In an adult male presenting with hematospermia and right testicular pain, epididymitis is the most likely diagnosis and should be treated empirically with antibiotics after ruling out testicular torsion with Doppler ultrasound. 1, 2

Immediate Priority: Rule Out Testicular Torsion

Any acute testicular pain must be treated as a surgical emergency until torsion is excluded. 1

Key Clinical Distinguishing Features

• Testicular torsion presents with sudden onset of severe scrotal pain, negative Prehn sign (pain NOT relieved with testicular elevation), and requires surgical intervention within 6-8 hours to prevent testicular loss 1, 2
• Epididymitis presents with gradual onset of pain, positive Prehn sign (pain relieved with elevation), and is the most common cause of testicular pain in adults, representing 85-90% of cases 1, 2

Urgent Diagnostic Imaging

• Obtain Duplex Doppler ultrasound immediately with sensitivity of 69-96.8% and specificity of 87-100% for testicular torsion 1
• Testicular torsion findings: Decreased or absent blood flow to the affected testicle, "whirlpool sign" of twisted spermatic cord, enlarged heterogeneous hypoechoic testis 1
• Epididymitis findings: Enlarged epididymis with increased blood flow on color Doppler, scrotal wall thickening, possible hydrocele 1, 2

Critical pitfall: False-negative Doppler evaluations occur in up to 30% of cases with partial torsion or spontaneous detorsion, so high clinical suspicion mandates immediate surgical exploration regardless of imaging 1

Hematospermia Evaluation

Age-Stratified Approach

• In men under 40 years: Infection is the most common identifiable cause of hematospermia 3
• In men 40 years and older: Iatrogenic causes from urogenital instrumentation dominate, but prostate cancer screening with PSA testing is mandatory even when other causes seem apparent 3

Initial Workup for Hematospermia

• Confirm true hematospermia by visual analysis of ejaculate versus postcoital bleeding from sexual partner 3
• Baseline laboratory studies: Urinalysis, semen analysis, complete blood count, serum chemistry panel, coagulation studies 3
• For men under 40 with transient hematospermia and no associated symptoms: Watchful waiting with reassurance is appropriate without imaging, as this represents a benign self-limited condition in the vast majority of cases 3

When to Pursue Advanced Imaging for Hematospermia

• Transrectal ultrasound (TRUS) should be the initial imaging modality for men ≥40 years or any age with persistent/recurrent hematospermia or associated symptoms, demonstrating abnormalities in 82-95% of cases 3
• MRI is indicated when TRUS results are negative or inconclusive, with superior soft tissue contrast and multiplanar high-resolution anatomic evaluation 3

Combined Presentation: Epididymitis as Unifying Diagnosis

The combination of hematospermia and testicular pain in an adult male strongly suggests epididymitis, which can cause both symptoms simultaneously. 2

Empiric Antibiotic Treatment for Epididymitis

In sexually active young adults:

• Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg oral twice daily for 10 days (covers C. trachomatis and N. gonorrhoeae) 2

In men >35 years or when enteric organisms suspected:

• Ofloxacin 300 mg oral twice daily for 10 days OR levofloxacino 500 mg oral once daily for 10 days 2

Treatment Monitoring

• Failure to improve within 3 days of initiating treatment requires reevaluation of diagnosis and therapy 2
• Persistent scrotal pain after completing antimicrobial treatment should prompt consideration of testicular cancer in the differential diagnosis 2

Common Benign Causes of Hematospermia

• Prostatic or ejaculatory duct calcifications 3
• Seminal vesicle or ejaculatory duct cysts 3
• Benign prostatic hyperplasia (in men ≥40 years) 3
• Ejaculatory duct obstruction 3

Red Flags Requiring Thorough Workup

• Persistent or recurrent hematospermia beyond several weeks requires thorough workup regardless of age 3
• Associated symptoms: Fever, chills, weight loss, bone pain 4
• Age ≥40 years: Mandatory prostate examination and PSA testing to evaluate for prostate cancer 3, 4

Critical consideration: Even with modern imaging, some cases remain idiopathic, but reassurance remains appropriate after thorough evaluation excludes serious pathology 3