What are the benign causes of hematospermia in otherwise healthy adult males?

Benign Causes of Hematospermia

The most common benign causes of hematospermia include urogenital infections (especially in men <40 years), prostatic and ejaculatory duct calcifications, seminal vesicle or ejaculatory duct cysts, benign prostatic hyperplasia, and iatrogenic injury from prior urogenital instrumentation—though the majority of cases remain idiopathic and self-limited. 1

Age-Stratified Benign Etiologies

Men Under 40 Years

• Urogenital tract infections represent the most common identifiable benign cause in this age group, accounting for approximately 40-55% of cases when a cause can be determined. 1, 2
• The condition is typically self-limited and resolves within several weeks without intervention. 3, 4
• Sexually transmitted infections should be considered in sexually active men presenting with associated lower urinary tract symptoms. 5

Men 40 Years and Older

• Iatrogenic causes from urogenital instrumentation (particularly prostate biopsy) dominate as the most common identifiable etiology in this age group. 1, 5
• Benign prostatic hyperplasia is a frequent structural abnormality that can cause hematospermia, though it represents an age-related change that may also be found in asymptomatic patients. 3, 1
• The majority of cases remain idiopathic even after thorough evaluation. 1

Common Benign Structural/Anatomic Causes

Calcifications and Calculi

• Prostatic or ejaculatory duct calcifications are among the most common benign findings in men with hematospermia. 1
• Prostatic calculi are frequently identified on imaging but may not represent the true causative factor, as they can be incidental age-related findings. 3, 1

Cystic Lesions

• Seminal vesicle cysts or dilatation (width >1.7 cm) can cause hematospermia and are well-visualized on transrectal ultrasound or MRI. 1
• Ejaculatory duct cysts represent another benign structural cause that may obstruct normal ejaculate flow. 1
• Nonobstructing prostatic cysts are age-related changes that can be found in asymptomatic patients. 3

Obstructive Pathology

• Ejaculatory duct obstruction can present with hematospermia, particularly when accompanied by semen analysis showing acidic pH, azoospermia, or low volume. 1
• Strictures at the verumontanum orifice or ejaculatory duct may be detected by vesiculoscopy. 3, 1

Rare Benign Causes

• Cowper gland masses are an uncommon but recognized benign cause of hematospermia. 1
• Vascular abnormalities such as internal pudendal artery hemorrhage can occur but are rare. 1

Important Clinical Caveats

Distinguishing True Hematospermia

• Visual confirmation that blood originates from the patient's ejaculate (rather than postcoital bleeding from a sexual partner) is essential before pursuing extensive workup. 1

Incidental Findings vs. True Causes

• Benign prostatic hyperplasia and prostatic calcifications are age-related changes that may be present in asymptomatic patients and should not automatically be assumed to be the cause of hematospermia. 3
• The presence of these findings on imaging does not exclude other etiologies and should not prevent appropriate cancer screening in men ≥40 years. 1

When Benign Causes Require Intervention

• While most benign causes are self-limited, specific treatable pathologies (such as ejaculatory duct obstruction or large symptomatic cysts) may benefit from targeted therapeutic interventions. 4
• Correction of any identified coagulopathy is indicated when systemic bleeding disorders contribute to hematospermia. 1

Idiopathic Hematospermia

• The majority of hematospermia cases remain idiopathic even after thorough clinical and imaging evaluation, particularly in younger men. 3, 1
• Idiopathic hematospermia is considered a benign, self-limited condition that typically resolves spontaneously within several weeks. 4, 6
• Reassurance is appropriate after excluding serious pathology through age-appropriate evaluation. 1