What is the appropriate evaluation and treatment for hematospermia in an otherwise healthy adult male?

Hematospermia: Evaluation and Treatment

Initial Management Strategy

For men under 40 years with a single episode of hematospermia and no associated symptoms, watchful waiting with reassurance is the appropriate management—no imaging or extensive workup is needed. 1, 2

Age-Stratified Approach

Men <40 Years Old

• Single, transient episode without symptoms: Reassurance and observation only 1, 2

• Baseline evaluation should include:

  • Visual confirmation that blood originates from the patient's ejaculate (not partner's postcoital bleeding) 2
  • Urinalysis 2, 3
  • Testing for sexually transmitted infections if lower urinary tract symptoms present 3
  • Blood pressure measurement to exclude hypertension 4
  • Complete blood count and coagulation studies 2

• Most common identifiable cause: Urogenital infection (39-55% of cases when a cause is found) 1, 2, 5

• Treatment: Directed at underlying infection if identified 3

Men ≥40 Years Old

All men 40 years and older with hematospermia require prostate cancer screening with PSA testing and digital rectal examination, regardless of whether another cause seems apparent. 1, 2, 3

• Most common cause: Iatrogenic from urogenital instrumentation (particularly prostate biopsy) 1, 3
• Mandatory initial workup:
  • Prostate-specific antigen (PSA) testing 1, 3
  • Digital rectal examination 3, 5
  • Urinalysis 2
  • Blood pressure measurement 4, 5
  • Coagulation studies 2

Imaging Algorithm

When to Image

Transrectal ultrasound (TRUS) should be the first-line imaging modality for:

• All men ≥40 years with hematospermia 1, 2
• Men of any age with persistent or recurrent hematospermia 1, 2
• Men with associated symptoms (fever, chills, weight loss, bone pain, lower urinary tract symptoms) 1, 3

TRUS Findings and Utility

• Diagnostic yield: TRUS demonstrates abnormalities in 82-95% of men with hematospermia 2
• Common findings identified:
  • Prostatic or ejaculatory duct calcifications (most common benign cause) 2
  • Seminal vesicle or ejaculatory duct cysts 2
  • Benign prostatic hyperplasia 2
  • Seminal vesicle dilatation (width >1.7 cm) 1, 2
  • Cowper gland masses 2

MRI Indications

MRI should be performed when TRUS results are negative or inconclusive. 1, 2

• Advantages over TRUS:
  • Operator-independent imaging 2
  • Superior soft tissue contrast 2
  • Multiplanar high-resolution anatomic evaluation 1, 2
  • Better determination of organ of origin for midline/paramedian cysts 1
  • More accurate assessment of ejaculatory duct obstruction 1
  • Better characterization of hemorrhage location and age within seminal tract 1

Special Diagnostic Considerations

Ejaculatory Duct Obstruction

TRUS is specifically recommended for men with semen analysis suggesting ejaculatory duct obstruction: acidic semen (pH <7.0), azoospermia, volume <1.5 mL, with normal testosterone and palpable vas deferens. 1

Vesiculoscopy

• Diagnostic accuracy: 74.5% for vesiculoscopy alone vs. 45.3% for TRUS alone 1
• Combined approach: Highest diagnostic accuracy when both modalities used together 1
• Most useful for: Detection of calculi and obstruction/stricture at verumontanum orifice or ejaculatory duct 1
• Indication: Persistent cases requiring urologic referral 2

Red Flags Requiring Thorough Workup

Persistent or recurrent hematospermia beyond several weeks requires thorough evaluation regardless of age. 2

Additional concerning features warranting immediate investigation:

• Fever, chills, weight loss, or bone pain 3
• Known history of cancer 3
• Known urogenital malformation 3
• Bleeding disorders 3
• New onset or non-reducible varicocele 1

Treatment Principles

• Primary approach: Treatment is directed at the underlying cause once identified 2
• Coagulopathy: Correct if identified 2
• Infection: Treat with appropriate antimicrobials 3
• Idiopathic cases: Reassurance remains appropriate after thorough evaluation excludes serious pathology 1, 2

Common Pitfalls to Avoid

• Do not perform routine imaging in men <40 years with single, transient episode and no symptoms—this leads to unnecessary anxiety and cost 1, 2
• Do not skip PSA testing in men ≥40 years even when another obvious cause (like recent prostate biopsy) is present 2
• Do not assume prostatic calcifications are the true cause—they are common incidental findings that may not represent actual etiology 2
• Do not forget to confirm blood originates from patient's ejaculate rather than partner's postcoital bleeding 2