What are the possible causes of gross hematuria and hematospermia in a 55-year-old male?

Causes of Gross Hematuria and Hematospermia in a 55-Year-Old Male

In a 55-year-old male presenting with both gross hematuria and hematospermia, the most critical concern is urologic malignancy—particularly bladder cancer, prostate cancer, or upper tract urothelial carcinoma—which requires urgent evaluation with cystoscopy and multiphasic CT urography regardless of other findings. 1, 2

Immediate Risk Assessment

The combination of gross hematuria with hematospermia in this age group carries substantial malignancy risk:

• Gross hematuria alone confers a 30-40% risk of underlying urologic malignancy, making urgent urologic referral mandatory even if bleeding appears self-limited 1, 2
• Males ≥60 years are automatically classified as high-risk, but at age 55 with gross hematuria, this patient requires the same comprehensive evaluation 1
• Hematospermia in men ≥40 years demands thorough investigation to exclude prostate cancer, seminal vesicle pathology, and other serious conditions 3

Primary Differential Diagnosis

Malignant Causes (Most Critical to Exclude)

• Bladder transitional cell carcinoma: The most frequently diagnosed malignancy in hematuria cases, accounting for 30-40% of gross hematuria 1, 2
• Prostate cancer: Can present with both hematuria and hematospermia, particularly when locally advanced 3
• Upper tract urothelial carcinoma: Affects renal pelvis or ureters, detected by CT urography 1
• Renal cell carcinoma: Less commonly causes hematospermia but is a critical consideration with gross hematuria 1
• Seminal vesicle carcinoma: Rare but can cause persistent hematospermia 3

Infectious/Inflammatory Causes

• Prostatitis: Accounts for 39-55% of hematospermia cases overall and is the most common infectious cause 4, 5, 6
• Seminal vesiculitis: Frequently identified on modern imaging as a source of bleeding in the seminal tract 3
• Urinary tract infection: Can cause both symptoms but does NOT exclude concurrent malignancy 1
• Epididymitis: May contribute to hematospermia 4, 5

Structural/Anatomic Causes

• Benign prostatic hyperplasia (BPH): Common in this age group and can cause both hematuria and hematospermia, but diagnosis of exclusion only after malignancy ruled out 1, 7
• Prostatic calculi: Identified on imaging, can cause recurrent bleeding 3
• Ejaculatory duct obstruction: Causes hematospermia and may be associated with prostatic cysts 3
• Seminal vesicle cysts: Detected by transrectal ultrasound or MRI 3
• Urolithiasis: Kidney or ureteral stones can cause gross hematuria 1

Vascular Causes

• Vascular malformations: Rare but can cause intractable hematospermia with or without hematuria 3
• Arteriovenous malformations: May require angiography for diagnosis 3

Iatrogenic Causes

• Recent prostate biopsy: The most common iatrogenic cause of hematospermia in men ≥40 years 6, 7
• Recent urologic instrumentation: Cystoscopy, catheterization, or other procedures 7

Systemic Causes

• Arterial hypertension: Predisposing factor for both symptoms 4, 6
• Coagulopathies or anticoagulation: Do NOT cause hematuria but may unmask underlying pathology; evaluation must proceed regardless 1, 2
• Hematologic disorders: Including bleeding diatheses 4, 6

Mandatory Diagnostic Evaluation

Immediate Laboratory Testing

• Microscopic urinalysis confirming ≥3 RBCs/HPF to verify true hematuria (not relying on dipstick alone, which has only 65-99% specificity) 1
• Serum creatinine and BUN to assess renal function 1
• Prostate-specific antigen (PSA) testing mandatory in all men ≥40 years with hematospermia 3
• Urine culture obtained before antibiotics if infection suspected 1
• Complete blood count to evaluate for anemia or coagulopathy 1

Imaging Studies

• Multiphasic CT urography (unenhanced, nephrographic, and excretory phases) is the preferred first-line imaging modality with 96% sensitivity and 99% specificity for urothelial malignancy 1, 2
• Transrectal ultrasound (TRUS) is the primary screening modality for evaluating the prostate and seminal tract in hematospermia, detecting abnormalities in 82-95% of cases 3
• MRI pelvis without and with IV contrast (rating 8/9) is indicated if TRUS is negative or inconclusive, particularly for suspected prostate cancer or ejaculatory duct obstruction 3

Endoscopic Evaluation

• Flexible cystoscopy is mandatory for all patients with gross hematuria to directly visualize bladder mucosa, urethra, and ureteral orifices 1, 2
• Cystoscopy cannot be deferred based on imaging findings alone, as bladder cancer requires direct visualization 1
• Flexible cystoscopy is preferred over rigid due to less pain with equivalent or superior diagnostic accuracy 1, 2

Additional Testing

• Voided urine cytology should be obtained in high-risk patients (age >60, smoking >30 pack-years, occupational exposures) to detect high-grade urothelial carcinomas 1, 2
• Semen analysis if hematospermia is the predominant symptom 6, 7

Critical Clinical Pitfalls to Avoid

• Never attribute gross hematuria to anticoagulation, BPH, or infection without completing full urologic evaluation—these may coexist with malignancy 1, 2
• Do not delay cystoscopy while pursuing additional imaging—bladder cancer cannot be excluded by CT alone 1
• Do not assume hematospermia is benign based on age alone—men ≥40 years require comprehensive evaluation 3
• Infection does not exclude malignancy—if hematuria persists 6 weeks after treating UTI, proceed immediately with full work-up 1
• Even self-limited gross hematuria requires urgent evaluation due to 30-40% malignancy risk 1, 2

Management Algorithm

1. Confirm true hematuria with microscopic urinalysis (≥3 RBCs/HPF) 1
2. Obtain PSA, serum creatinine, urine culture, and CBC 1
3. Order multiphasic CT urography to evaluate upper tracts, kidneys, ureters, and bladder 1, 2
4. Perform transrectal ultrasound to evaluate prostate and seminal vesicles 3
5. Schedule urgent flexible cystoscopy (within 24-48 hours) to visualize bladder 1, 2
6. Obtain voided urine cytology given age and symptom severity 1, 2
7. If initial work-up negative, consider MRI pelvis for detailed seminal tract evaluation 3
8. If all imaging and cystoscopy negative, repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring 1, 2

When to Consider Nephrology Referral

• Tea-colored or cola-colored urine suggests glomerular source 1
• Significant proteinuria (>0.5 g/g protein-to-creatinine ratio) 1
• >80% dysmorphic RBCs or red cell casts on microscopy 1
• Elevated serum creatinine or declining renal function 1
• Hypertension accompanying hematuria and proteinuria 1

Note: Glomerular features do not eliminate the need for complete urologic evaluation—both evaluations should proceed in parallel 1