Hematospermia

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 Overview of Sexually Transmitted Infections Sexually transmitted infection (STI) refers to infection with a pathogen that is transmitted through blood, semen, vaginal fluids, or other body fluids during oral, anal, or genital sex with... read more (STIs—eg, unprotected intercourse, multiple sex partners), known bleeding disorders, and known disorders that predispose to bleeding (eg, cirrhosis Cirrhosis Cirrhosis is a late stage of hepatic fibrosis that has resulted in widespread distortion of normal hepatic architecture. Cirrhosis is characterized by regenerative nodules surrounded by dense... read more ). 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 Schistosomiasis Schistosomiasis is infection with blood flukes of the genus Schistosoma, which are acquired transcutaneously by swimming or wading in contaminated freshwater. The organisms infect the... read more is endemic.

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.

The following findings are of particular concern:

Patients whose symptoms followed prostate biopsy Prostate biopsy Biopsy of the urinary tract requires a trained specialist (nephrologist, urologist, or interventional radiologist). Indications for diagnostic biopsy include unexplained nephritic or nephrotic... read more 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 Prostate Cancer Prostate cancer is usually adenocarcinoma. Symptoms are typically absent until tumor growth causes hematuria and/or obstruction with pain. Diagnosis is suggested by digital rectal examination... read more , benign prostatic hyperplasia Benign Prostatic Hyperplasia (BPH) Benign prostatic hyperplasia (BPH) is nonmalignant adenomatous overgrowth of the periurethral prostate gland. Symptoms are those of bladder outlet obstruction—weak stream, hesitancy, urinary... read more , or prostatitis Prostatitis Prostatitis refers to a disparate group of prostate disorders that manifests with a combination of predominantly irritative or obstructive urinary symptoms and perineal pain. Some cases result... read more . Urethral discharge suggests a sexually transmitted infection Overview of Sexually Transmitted Infections Sexually transmitted infection (STI) refers to infection with a pathogen that is transmitted through blood, semen, vaginal fluids, or other body fluids during oral, anal, or genital sex with... read more (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.

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

These findings are of particular concern in men > 40 years. Testing includes urinalysis, urine culture, prostate-specific antigen (PSA) testing Prostate-specific antigen (PSA) levels Benign prostatic hyperplasia (BPH) is nonmalignant adenomatous overgrowth of the periurethral prostate gland. Symptoms are those of bladder outlet obstruction—weak stream, hesitancy, urinary... read more , 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.