Hematospermia is blood in semen. It is often frightening to patients but is usually benign. Men sometimes mistake hematuria or blood from a sexual partner for hematospermia.
Pathophysiology of Hematospermia
Semen is composed of sperm from the distal epididymis and fluids from the seminal vesicles, prostate, and Cowper and bulbourethral glands. Thus, a lesion anywhere along this pathway could introduce blood into the semen.
Etiology of Hematospermia
Most cases of hematospermia are
Idiopathic and benign
Such cases resolve spontaneously within a few days to a few months.
The most common known cause is
Less common causes include other instrumentation, benign prostatic hyperplasia, infections (eg, prostatitis, urethritis, epididymitis), and prostate cancer (in men > 35 to 40 years). Occasionally, tumors of the seminal vesicles and testes are associated with hematospermia. Hemangiomas of the prostatic urethra or spermatic duct may cause massive hematospermia.
Schistosoma haematobium, a parasitic fluke that causes significant disease in Africa, parts of the Middle East, and southeast Asia, can invade the urinary tract, causing hematuria and not infrequently hematospermia. Schistosomiasis is a consideration only in men who have spent time in areas where the disorder is endemic. Tuberculosis is also an uncommon cause of hematospermia.
Evaluation of Hematospermia
History
History of present illness should note the duration of symptoms. Patients who do not volunteer information should be asked specifically about a recent prostate biopsy or any trauma (eg, urologic instrumentation, penile injections, trauma related to sexual activity). Important associated symptoms include hematuria, difficulty starting or stopping urine flow, nocturia, burning with urination, and penile discharge. Association with sexual activity should also be noted.
Review of systems should seek symptoms of causative disorders, including easy bruising, frequent nosebleeds, and excessive gum bleeding with tooth brushing or dental procedures (hematologic disorders), and fevers, chills, night sweats, bone pain, or weight loss (prostate infection or cancer).
Past medical history should specifically ask about known disorders of the prostate, radiation treatment for prostate cancer, history of or exposure to tuberculosis (TB) or HIV, risk factors for sexually transmitted infections (STIs—eg, unprotected intercourse, multiple sex partners), known bleeding disorders, and known disorders that predispose to bleeding (eg, cirrhosis). Drug history should note use of anticoagulants or antiplatelet drugs. Patients should be asked about any family history of prostate cancer and travel to regions where schistosomiasis is endemic.
Physical examination
The external genitals should be inspected and palpated for signs of inflammation (erythema, mass, tenderness), particularly along the course of the epididymis. A digital rectal examination is done to examine the prostate for enlargement, tenderness, or a lump.
Red flags
The following findings are of particular concern:
Symptoms lasting > 1 month in the absence of a recent prostate biopsy
Palpable lesion along the epididymis or in the prostate
Travel to a region where schistosomiasis is prevalent
Systemic symptoms (eg, fevers, weight loss, night sweats)
Interpretation of findings
Patients whose symptoms followed prostate biopsy can be reassured that the hematospermia is harmless and will go away, although it often persists for several months.
Healthy, young patients with a brief duration of hematospermia, an otherwise normal history and examination, and no travel history likely have an idiopathic disorder.
Patients with abnormal findings on prostate examination may have prostate cancer, benign prostatic hyperplasia, or prostatitis. Urethral discharge suggests a sexually transmitted infection (STI).
Epididymal tenderness suggests an STI or rarely tuberculosis (more likely in patients with risk factors of exposure or who are immunocompromised).
Characteristic findings of a bleeding disorder or use of drugs that increase risk of bleeding suggests a precipitating cause but does not rule out an underlying disorder.
Testing
In most cases, especially in men < 35 to 40 years, hematospermia is almost always benign. If no significant abnormality is found on physical examination (including digital rectal examination), urinalysis, urine culture, and STI testing are done, but no further work-up is necessary.
Patients who may have a more serious underlying disorder and should have testing include those who have
A longer duration of symptoms (> 1 month)
Abnormal examination findings
Fevers, weight loss, or night sweats
These findings are of particular concern in men > 40 years. Testing includes urinalysis, urine culture, prostate-specific antigen (PSA) testing, and transrectal ultrasonography. Occasionally, MRI and cystoscopy are needed. Semen inspection and analysis are rarely done, but it can be useful when travel history suggests possible exposure to S. haematobium.
Treatment of Hematospermia
Treatment is directed at the cause if known. For almost all men, reassurance that hematospermia is not a sign of cancer and does not affect sexual function is the only intervention necessary. If prostatitis
Key Points
Most cases are idiopathic or follow prostate biopsy.
Testing is required mainly for patients with prolonged symptoms or abnormal examination findings.
Schistosomiasis should be considered in patients who have traveled to endemic areas.
