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Hematospermia

by Anuja P. Shah, MD

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

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

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

  • Prostate biopsy

Less common causes include other instrumentation, benign prostatic hyperplasia, infections (eg, prostatitis, urethritis, epididymitis), and prostate cancer (in men > 35 to 40 yr). 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 (and to a lesser extent in India and parts of the Middle East), 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. TB is also an uncommon cause of hematospermia.

Evaluation

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. 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, history of or exposure to TB or HIV, risk factors for sexually transmitted diseases (STDsā€”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 mo

  • 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.

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 an STD.

Epididymal tenderness suggests an STD or rarely TB (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 yr, hematospermia is almost always benign. If no significant abnormality is found on physical examination (including digital rectal examination), urinalysis, urine culture, and STD 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 mo)

  • Hematuria

  • Obstructive urinary symptoms

  • Abnormal examination findings

  • Fevers, weight loss, or night sweats

These findings are of particular concern in men > 40 yr. Testing includes urinalysis, urine culture, prostate-specific antigen (PSA) testing, and transrectal ultrasonography (TRUS). 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

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 is suspected, it can be treated with trimethoprim/sulfamethoxazole or a fluoroquinolone for 4 to 6 wk.

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.

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