What is the appropriate evaluation and management for hematospermia (blood in the ejaculate)?

Evaluation and Management of Hematospermia

For men under 40 years with a single, asymptomatic episode of hematospermia, reassurance and watchful waiting without imaging is the appropriate management; however, all men 40 years and older require prostate cancer screening with PSA testing and digital rectal examination, plus transrectal ultrasound imaging. 1

Initial Assessment for All Patients

Before proceeding with any workup, confirm that blood truly originates from the patient's ejaculate rather than postcoital bleeding from a sexual partner—this requires visual confirmation of blood in the ejaculate. 1

The baseline evaluation includes: 1

• Visual analysis of ejaculate
• Urinalysis
• Semen analysis
• Complete blood count
• Serum chemistry panel
• Coagulation studies
• Blood pressure measurement (to identify hypertension as a systemic cause) 2
• Digital rectal examination to assess the prostate 2

Age-Stratified Management Algorithm

Men Under 40 Years

Single, asymptomatic episode:

• Watchful waiting with reassurance is appropriate without any imaging or extensive workup 1
• This represents a benign self-limited condition in the vast majority of cases 1
• When a cause is identified in this age group, urogenital infection accounts for 40-55% of cases 1

Persistent, recurrent, or symptomatic episodes:

• Proceed to imaging with transrectal ultrasound (TRUS) 1
• Consider urogenital infection as the primary etiology and treat accordingly 1, 2

Men 40 Years and Older

Mandatory initial workup for ALL patients in this age group: 1

• Prostate cancer screening with PSA testing and digital rectal examination—this is non-negotiable even when other causes seem apparent 1
• Transrectal ultrasound (TRUS) as first-line imaging 1

The most common identifiable cause in this population is iatrogenic injury from prior urogenital instrumentation, especially prostate biopsy. 1, 2

Imaging Strategy

First-Line: Transrectal Ultrasound (TRUS)

TRUS is indicated for: 1

• All men ≥40 years with hematospermia
• Patients of any age with persistent or recurrent episodes
• Any patient with accompanying systemic symptoms (fever, chills, weight loss, bone pain) or lower urinary tract symptoms (dysuria)

TRUS demonstrates abnormalities in 82-95% of men with hematospermia and can identify: 1

• Prostatic calcifications or calculi
• Ejaculatory duct or seminal vesicle cysts
• Seminal vesicle dilatation (width >1.7 cm is abnormal)
• Benign prostatic hyperplasia
• Cowper gland masses

Special indication: When semen analysis suggests ejaculatory duct obstruction (acidic pH, azoospermia, low volume) with normal testosterone and palpable vas deferens, TRUS is specifically recommended. 1

Second-Line: MRI

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

MRI offers superior advantages: 1

• Operator-independent imaging
• Superior soft tissue contrast
• Multiplanar high-resolution anatomic evaluation
• Better delineation of the organ of origin for midline/paramedian cysts
• More accurate assessment of ejaculatory duct obstruction
• Better characterization of hemorrhage age and location within the seminal tract

Advanced Diagnostic Procedures

Vesiculoscopy may be necessary for persistent cases, with diagnostic accuracy of 74.5% versus 45.3% for TRUS alone—combined use yields the highest accuracy. 1 This modality is particularly useful for detecting calculi and strictures at the verumontanum orifice or ejaculatory duct. 1

Red-Flag Indicators Requiring Immediate Investigation

The emergence of a new, non-reducible varicocele constitutes a red-flag sign that mandates immediate investigation. 1

Treatment Approach

Management is directed at the underlying cause once identified: 1

• Antimicrobial therapy for urogenital infections
• Correction of coagulopathy if identified
• Urologic referral for structural abnormalities requiring intervention

Even with modern imaging, some cases remain idiopathic, but reassurance remains appropriate after thorough evaluation excludes serious pathology. 1

Critical Pitfalls to Avoid

Do not perform routine imaging in men <40 years with a single, transient, asymptomatic episode—this adds unnecessary anxiety and cost without clinical benefit. 1

Never omit PSA testing in men ≥40 years, even when an obvious alternative cause (such as recent prostate biopsy) is present, as prostate cancer is a neoplastic cause that must not be missed. 1

Do not assume the cause is benign based on age alone—persistent or recurrent hematospermia beyond several weeks requires thorough workup regardless of age. 1