Evaluation and Treatment 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
Initial Assessment
The first critical step is confirming that blood truly originates from the patient's ejaculate rather than postcoital bleeding from a sexual partner, which requires visual confirmation of blood in the ejaculate 1.
Baseline workup should include:
- Visual analysis of ejaculate 1
- Urinalysis 1, 2
- Semen analysis 1
- Complete blood count 1
- Serum chemistry panel 1
- Coagulation studies 1
- Blood pressure measurement to identify hypertension 3
- Digital rectal examination to assess the prostate 2, 4
Age-Stratified Management Algorithm
Men Under 40 Years
Single episode without associated symptoms:
- Reassurance and watchful waiting without imaging 1, 2
- No further evaluation needed in the absence of risk factors (history of cancer, known urogenital malformation, bleeding disorders) 2
Associated with lower urinary tract symptoms:
- Testing for sexually transmitted infections 2
- Urinalysis 2
- Treatment directed at identified infection 2
- Infection is the most common identifiable cause in this age group 1
Men 40 Years and Older
Mandatory evaluation includes:
- Prostate-specific antigen (PSA) testing is mandatory even when other causes seem apparent 1
- Prostate examination 2
- Iatrogenic causes from urogenital instrumentation (especially prostate biopsy) are the most common identifiable cause in this age group 1, 2
Initial imaging modality:
- Transrectal ultrasound (TRUS) should be the first imaging study 1
- TRUS demonstrates abnormalities in 82-95% of men with hematospermia 1
- Can identify prostatic calcifications, ejaculatory duct or seminal vesicle cysts, benign prostatic hyperplasia, and Cowper gland masses 1
Persistent or Recurrent Hematospermia (Any Age)
Persistent or recurrent hematospermia beyond several weeks requires thorough workup regardless of age 1
Advanced imaging:
- MRI is indicated when TRUS results are negative or inconclusive 1
- MRI offers operator-independent imaging, superior soft tissue contrast, and multiplanar high-resolution anatomic evaluation 1
Urologic referral:
- Consider vesiculoscopy for persistent cases, with diagnostic accuracy of 74.5% versus 45.3% for TRUS alone 1
Common Etiologies by Age
Under 40 years:
- Infection (most common identifiable cause) 1
- Prostatic or ejaculatory duct calcifications 1
- Seminal vesicle or ejaculatory duct cysts 1
40 years and older:
- Iatrogenic from urogenital instrumentation (most common) 1
- Benign prostatic hyperplasia 1
- Ejaculatory duct obstruction 1
- Prostate cancer (must not be missed) 1
Treatment Approach
Treatment is directed at the underlying cause once identified:
- Correction of coagulopathy if present 1
- Appropriate antimicrobial therapy for genitourinary infections 4
- Definitive treatment of malignant lesions if identified 4
- Even with modern imaging, some cases remain idiopathic, but reassurance is appropriate after thorough evaluation excludes serious pathology 1
Critical Pitfalls to Avoid
- Never skip PSA testing in men 40 years and older, even when another cause seems obvious 1
- Do not perform extensive imaging in young men (<40 years) with a single episode and no symptoms 1, 2
- Always distinguish true hematospermia from partner bleeding through visual confirmation 1
- Do not dismiss persistent or recurrent cases as benign without complete evaluation 1