What is the appropriate initial work‑up and management for a 39‑year‑old man presenting with an isolated episode of haematospermia?

Management of Haematospermia in a 39-Year-Old Man

For a 39-year-old man with an isolated episode of haematospermia and no associated symptoms, watchful waiting with reassurance is the appropriate management—no imaging or extensive work-up is required. 1

Initial Clinical Assessment

The first step is to confirm 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 Work-Up for This Age Group

For men under 40 years presenting with a single, asymptomatic episode, the evaluation should include: 1

• Visual analysis of ejaculate to confirm true haematospermia 1
• Urinalysis to exclude urinary tract infection 1
• Blood pressure measurement to identify hypertension as a potential cause 1, 2
• Digital rectal examination to assess for prostatic abnormalities 1
• Complete blood count and coagulation studies if bleeding disorders are suspected 1

PSA testing is NOT required in this 39-year-old patient, as prostate cancer screening is mandatory only for men ≥40 years. 1

Age-Specific Context

In men under 40 years, infection is the most common identifiable cause of haematospermia (accounting for 40-55% of cases when a cause is found), though the majority of cases remain idiopathic and self-limited. 1, 3 This contrasts sharply with men 40 years and older, where iatrogenic causes from urogenital instrumentation dominate. 1

When to Pursue Further Investigation

Imaging should NOT be performed for this patient unless specific red flags are present. 1 Further work-up is indicated only if:

• Persistent or recurrent episodes beyond several weeks occur 1
• Associated systemic symptoms develop (fever, chills, weight loss, bone pain) 1
• Lower urinary tract symptoms are present (dysuria, frequency, urgency) 1
• A new, non-reducible varicocele emerges (red-flag sign requiring immediate investigation) 1

Imaging Algorithm If Further Work-Up Becomes Necessary

If the patient develops persistent or recurrent haematospermia, the imaging strategy should be: 1

1. First-line: Transrectal ultrasound (TRUS) - demonstrates abnormalities in 82-95% of men with haematospermia and can identify prostatic calcifications, ejaculatory duct or seminal vesicle cysts, and inflammatory changes 1, 4

2. Second-line: MRI - indicated when TRUS results are negative or inconclusive, offering superior soft tissue contrast, operator-independent acquisition, and multiplanar high-resolution anatomic evaluation 1, 4

Treatment Approach

For this 39-year-old with an isolated episode:

• Reassurance is the primary intervention, as 80-90% of cases are benign and self-limited 4
• No antimicrobial therapy is indicated unless urinalysis or clinical findings suggest active infection 1
• No correction of coagulopathy unless laboratory studies identify a bleeding disorder 1

Critical Pitfalls to Avoid

Do not order routine imaging in men <40 years with a single, transient, asymptomatic episode, as this adds unnecessary anxiety and cost without improving outcomes. 1 The vast majority of these cases represent benign, self-limited conditions that resolve spontaneously. 1, 5

Do not omit follow-up instructions: The patient should be counseled to return if haematospermia persists beyond several weeks or recurs, as this would trigger the need for TRUS and more comprehensive evaluation. 1