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 Hematospermia: A Merck Manual of Patient Symptoms podcast
Hematospermia is blood in semen. It is often frightening to patients but is usually benign.
Pathophysiology
Semen is composed of sperm from the distal epididymis and fluids from the seminal vesicles, prostate, and Cowper's and bulbourethral glands. Thus, a lesion anywhere along this pathway could introduce blood into the semen.
Etiology
Most cases of hematospermia are
Such cases resolve spontaneously within a few days to a few months.
The most common known cause is
Less common causes include 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 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.
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.
Review of systems should note symptoms of excessive bleeding, including easy bruising, frequent nosebleeds, and excessive gum bleeding with tooth brushing or dental procedures.
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 (STDs—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:
Interpretation of findings
Patients whose symptoms followed prostate biopsy can be reassured that the hematospermia is harmless and will go away.
Healthy 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 and urine culture 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
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
Last full review/revision September 2009 by Seyed-Ali Sadjadi, MD
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