What is the term for blood in semen (hematospermia) and what are its possible causes?

Blood in Semen: Hematospermia

Blood in semen is called hematospermia (or hemospermia), and it is most commonly caused by infectious/inflammatory conditions of the urogenital tract (accounting for approximately 40% of cases), with iatrogenic trauma from prostate biopsies being the single most common identifiable cause overall. 1

What is Hematospermia?

Hematospermia is defined as the presence of blood in the ejaculate or semen. 1 While it causes significant anxiety for patients due to fears of malignancy or venereal disease, it is typically a benign and self-limiting condition, particularly in younger men. 1

Common Causes

Most Frequent Etiologies

Iatrogenic causes are the most common overall:

• Transrectal ultrasound-guided prostate biopsy is the single most common cause of hematospermia 2, 3
• This is a predictable consequence of prostatic procedures 4

Infectious/inflammatory conditions are the most common non-iatrogenic cause:

• Account for approximately 40% of all hematospermia cases 1
• Most common etiology in men <40 years of age 1
• Include prostatitis, seminal vesiculitis, urethritis, and epididymitis 1, 5
• Common pathogens include Escherichia coli and Chlamydia trachomatis 5

Anatomic and Structural Causes

Hematospermia may originate from pathology in multiple locations 1:

• Prostate gland: prostatic calculi, cysts, benign prostatic hypertrophy 1
• Seminal tract: seminal vesicles (a main site of bleeding), vasa deferentia, ejaculatory ducts 1
• Other structures: verumontanum, urethra, urinary bladder, epididymis, testes 1
• Specific lesions: ductal obstruction, ejaculatory duct obstruction, prostatic cyst formation 1
• Vascular abnormalities: rarely, vascular malformations 1

Less Common but Important Causes

• Malignancy: Prostate, testicular, and other genitourinary cancers are rarely the cause of hematospermia 2, 3
• Systemic conditions: arterial hypertension, hematologic disorders, coagulation abnormalities 4
• Idiopathic: While historically most cases were labeled idiopathic, improved imaging has significantly decreased this category 1

Clinical Approach by Patient Age and Presentation

Men <40 Years with Transient/Single Episode

Watchful waiting and reassurance are appropriate for young men with a single episode and no other symptoms. 1

Essential evaluation includes 1:

• Detailed history focusing on: timing of blood appearance, sexual history, recent procedures, systemic symptoms
• Physical examination including: blood pressure measurement, abdominal palpation for organomegaly, genital examination for testicular masses or urethral discharge, digital rectal examination of prostate 1
• Basic laboratory testing: urinalysis, urine culture, visual semen analysis, complete blood count, coagulation studies 1

Imaging is NOT indicated for this population as the condition is typically benign and self-limiting. 1

Men ≥40 Years OR Persistent/Symptomatic Hematospermia

All patients ≥40 years should be screened for prostate cancer with prostate-specific antigen (PSA) testing. 1

Transrectal ultrasound (TRUS) is the first-line imaging modality (ACR appropriateness rating: 8/9). 1

TRUS advantages 1:

• Safe, inexpensive, radiation-free, effective
• Detects abnormalities in 82-95% of men with hematospermia 1
• Can identify: calcifications/calculi, cysts, benign prostatic hypertrophy, prostatitis, Cowper gland masses 1
• Allows TRUS-guided aspiration or biopsy if needed 1

MRI pelvis is indicated when TRUS is negative or inconclusive (ACR appropriateness rating: 7-8/9). 1

MRI advantages 1:

• Superior soft tissue contrast and multiplanar capability
• Operator-independent (unlike TRUS)
• Better for determining organ of origin of cysts and evaluating ejaculatory duct obstruction 1
• Can assess for suspected prostate cancer (should include dynamic contrast-enhanced sequences) 1

Important Clinical Pitfalls

Common age-related findings may not be causative: Benign prostatic hyperplasia and prostatic calcifications are age-related changes that can be found in asymptomatic patients and may not explain the hematospermia. 1

Partner bleeding can be mistaken for hematospermia: Always determine the true origin of bleeding through careful history, as postcoital hemorrhage from a sexual partner may be confused with hematospermia. 1

Hematospermia in epididymitis appears early: In patients developing acute epididymitis, hematospermia may appear as early as 24 hours before scrotal symptoms develop (occurs in 15% of cases). 5

PSA elevation is expected: Hematospermia itself can cause elevated PSA levels (median 3.1 ng/mL in epididymitis patients with hematospermia vs 1.8 ng/mL without). 5

Imaging Modalities to Avoid

CT scanning is usually NOT appropriate (ACR appropriateness rating: 1-2/9) due to radiation exposure and poor soft tissue contrast for differentiating prostatic and seminal tract pathology. 1

Pelvic angiography is reserved only for intractable hematospermia when all other evaluations are unrevealing, and can provide therapeutic embolization if vascular malformation is identified. 1

Sexual and Fertility Implications

Hematospermia has several important consequences 2, 3:

• Causes significant anxiety affecting libido
• May increase risk of erectile dysfunction
• Can compromise fertility, particularly when cryopreservation is needed
• Persistent hematospermia at 14 days post-infection is associated with massive leukocytospermia, reduced sperm concentration, and abnormal seminal markers 5