Ultrasound for Isolated Hematospermia in a Young Man
In a young healthy man under 40 years of age with a single episode of hematospermia and a normal physical exam, ultrasound is NOT indicated—watchful waiting with reassurance is the appropriate management. 1
Clinical Approach by Age and Presentation
Men Under 40 Years with Transient/Episodic Hematospermia
No imaging is recommended for this population because hematospermia is typically a benign, self-limited condition that resolves spontaneously within several weeks. 1, 2
The ACR Appropriateness Criteria assigns transrectal ultrasound (TRUS) a rating of 3 ("usually not appropriate") for men under 40 with transient hematospermia and no other symptoms. 1
Watchful waiting, reassurance, and routine clinical evaluation suffice in the absence of risk factors such as history of cancer, known urogenital malformation, bleeding disorders, or associated symptoms. 1, 3
Initial workup should be limited to:
When a cause is identified in men under 40, urogenital infection accounts for 40-55% of cases, making this the most common identifiable etiology. 2, 3
When Imaging BECOMES Indicated (Any Age)
TRUS is the first-line imaging modality (rated 8, "usually appropriate") in the following scenarios: 1
- Age ≥40 years (regardless of symptom duration) 1
- Persistent or recurrent hematospermia at any age (beyond several weeks) 1, 2
- Associated symptoms or signs of disease including: 1
- Fever, chills, weight loss, bone pain
- Lower urinary tract symptoms (dysuria, frequency)
- Abnormal digital rectal examination
- New non-reducible varicocele (red flag requiring immediate workup) 2
TRUS Performance Characteristics
TRUS demonstrates abnormalities in 82-95% of men with hematospermia, though many findings (prostatic calcifications, benign prostatic hyperplasia, non-obstructing cysts) may be incidental age-related changes rather than the true cause. 1, 4, 5
Common TRUS findings include: 1, 4
- Calcifications or calculi in prostate, ejaculatory ducts, or seminal vesicles
- Seminal vesicle, ejaculatory duct, or prostatic cysts
- Prostatitis or seminal vesiculitis
- Benign prostatic hyperplasia (age-related)
MRI as Second-Line Imaging
MRI is indicated when TRUS is negative or inconclusive (rated 7-8, "usually appropriate"). 1
MRI advantages over TRUS: 1, 6
- Operator-independent acquisition
- Superior soft-tissue contrast
- Multiplanar high-resolution anatomic evaluation
- Better characterization of midline/paramedian cysts' organ of origin
- More accurate assessment of ejaculatory duct obstruction
- Superior delineation of hemorrhage location and age within seminal tract
Critical Age-Based Screening Requirement
All men ≥40 years with hematospermia MUST undergo prostate cancer screening with PSA testing and digital rectal examination, even when another apparent cause (such as recent prostate biopsy) is identified. 1, 2, 3
In the study by Han et al., all 8 malignancies (3.0% of 270 patients) occurred exclusively in men over 40 years old, underscoring the importance of age-stratified evaluation. 5
Common Pitfalls to Avoid
Do not order imaging in young men (<40) with isolated transient hematospermia—this adds unnecessary anxiety, cost, and may reveal incidental findings of unclear significance. 1, 2
Do not skip PSA testing in men ≥40 years even when an obvious benign cause seems present, as malignancy can coexist. 2
Do not assume prostatic calcifications or benign prostatic hyperplasia are causative—these are often incidental age-related findings in asymptomatic men. 1, 2
Confirm the blood is truly from the patient's ejaculate rather than postcoital bleeding from a sexual partner before initiating any workup. 1, 2