What is the appropriate management for a patient presenting with hematospermia?

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 the appropriate management, as this represents a benign self-limited condition in the vast majority of cases. 1

Age-Based Management Algorithm

Men Under 40 Years

Single Episode Without Symptoms:

• Perform baseline workup only: visual confirmation that blood originates from ejaculate (not partner), urinalysis, and blood pressure measurement 1, 2
• No imaging is required for transient hematospermia without associated symptoms 1
• Reassure the patient that this is typically benign and self-limiting 2, 3

With Associated Lower Urinary Tract Symptoms:

• Infection is the most common identifiable cause in this age group 1, 2
• Add testing for sexually transmitted infections and treat as indicated 2
• Consider semen analysis, complete blood count, serum chemistry panel, and coagulation studies 1
• Empiric antibiotic therapy targeting urogenital infections is appropriate 3

Men 40 Years and Older

Mandatory Initial Evaluation:

• Prostate-specific antigen (PSA) testing is mandatory even when other causes seem apparent, as prostate cancer must not be missed 1, 3
• Digital rectal examination to evaluate for prostate abnormalities 2, 4
• Complete baseline workup: urinalysis, blood pressure measurement, complete blood count, coagulation studies 1, 4
• Note that iatrogenic causes from urogenital instrumentation (especially prostate biopsy) are the most common identifiable cause in this age group 1, 2

Imaging Strategy:

• Transrectal ultrasound (TRUS) should be the initial imaging modality, as it demonstrates abnormalities in 82-95% of men with hematospermia 1
• TRUS can identify prostatic calcifications, ejaculatory duct or seminal vesicle cysts, benign prostatic hyperplasia, and Cowper gland masses 1
• MRI is indicated when TRUS results are negative or inconclusive, offering superior soft tissue contrast and multiplanar high-resolution anatomic evaluation 1

Red Flags Requiring Thorough Workup (Any Age)

Persistent or recurrent hematospermia beyond several weeks requires thorough investigation regardless of age 1, 2:

• Fever, chills, weight loss, or bone pain mandate immediate comprehensive evaluation 2
• Recurrent episodes even in younger men warrant PSA testing and imaging 3, 4
• Known bleeding disorders or anticoagulation use requires coagulation studies and correction of coagulopathy 1, 5

Common Benign Causes to Identify

• Prostatic or ejaculatory duct calcifications (common benign finding) 1
• Seminal vesicle or ejaculatory duct cysts 1
• Benign prostatic hyperplasia in men ≥40 years 1
• Arterial hypertension (check blood pressure in all patients) 4, 5

Treatment Approach

• Treatment is directed at the underlying cause once identified 1, 3
• Infectious causes respond to appropriate antimicrobial therapy 3
• Urologic referral for vesiculoscopy may be necessary for persistent cases, with diagnostic accuracy of 74.5% versus 45.3% for TRUS alone 1
• Even with modern imaging, some cases remain idiopathic, but reassurance is appropriate after thorough evaluation excludes serious pathology 1, 6

Critical Pitfall to Avoid

Do not assume hematospermia is benign in men ≥40 years without PSA testing and prostate examination, as prostate cancer is a neoplastic cause that must not be missed 1, 2. The majority of cases may be idiopathic or benign, but the consequences of missing malignancy are severe for morbidity and mortality.