How should I evaluate and manage a 27-year-old man presenting with isolated hematospermia?

Management of Hematospermia in a 27-Year-Old Man

For a 27-year-old man with isolated hematospermia and no associated symptoms, reassure him that this is a benign, self-limited condition and adopt a watchful waiting approach without any imaging or extensive workup. 1

Initial Assessment

Confirm that the blood truly originates from the patient's ejaculate rather than postcoital bleeding from a sexual partner by obtaining visual confirmation of blood in the ejaculate. 1

Perform a focused baseline evaluation including:

• Visual analysis of the ejaculate to confirm true hematospermia 1
• Urinalysis to exclude urinary tract infection or hematuria 1
• Semen analysis if infection is suspected 1
• Complete blood count and coagulation studies to rule out bleeding disorders 1
• Blood pressure measurement to identify hypertension as a potential cause 2
• Digital rectal examination to assess for prostatic abnormalities 3

Age-Specific Management Strategy

In men under 40 years, infection is the most common identifiable cause of hematospermia when a cause is found (accounting for 40-55% of identified cases). 1 However, the vast majority of cases in this age group are idiopathic and self-limited, resolving within several weeks without intervention. 1

For your 27-year-old patient with a single, asymptomatic episode:

• No imaging is required – routine imaging should not be performed as it adds unnecessary anxiety and cost 1
• Provide reassurance that this represents a benign condition in the vast majority of cases 1
• Watchful waiting is the appropriate management strategy 1

When to Pursue Further Investigation

Proceed with additional workup only if:

• Persistent or recurrent episodes beyond several weeks occur 1
• Associated symptoms develop, including fever, chills, weight loss, bone pain, or dysuria 1
• Lower urinary tract symptoms suggest infection 4

If infection is suspected based on symptoms, limit the workup to urinalysis and testing for sexually transmitted infections, with treatment as indicated. 4

Imaging Indications (Not Applicable to This Case)

Transrectal ultrasound (TRUS) should be reserved for men ≥40 years or any age with persistent/recurrent hematospermia or associated symptoms, as it demonstrates abnormalities in 82-95% of men with hematospermia. 1 MRI is indicated only when TRUS results are negative or inconclusive. 1

Critical Pitfall to Avoid

Do not order routine imaging in this young patient with a single, transient, asymptomatic episode – this is the most common error in management and leads to unnecessary anxiety and healthcare costs. 1 The natural history in younger men is benign and self-limited, with resolution typically occurring within several weeks. 1

Treatment Approach

Since the majority of cases in men under 40 remain idiopathic even after evaluation, and given the benign natural history, treatment is directed only at identified underlying causes (such as antimicrobial therapy for documented infection or correction of coagulopathy if identified). 1 In the absence of an identified cause, reassurance alone is appropriate and sufficient. 1