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Hematospermia

By

Geetha Maddukuri

, MD, Saint Louis University

Last full review/revision Jan 2021| Content last modified Jan 2021
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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

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 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 vasculature... read more is a consideration only in men who have spent time in areas where the disorder is endemic. Tuberculosis Genitourinary TB Tuberculosis outside the lung usually results from hematogenous dissemination. Sometimes infection directly extends from an adjacent organ. Symptoms vary by site but generally include fever... read more Genitourinary TB 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 diseases Overview of Sexually Transmitted Diseases Sexually transmitted diseases (STDs), also termed sexually transmitted infections (STIs), can be caused by a number of microorganisms that vary widely in size, life cycle, the diseases and symptoms... read more (STDs—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 vasculature... read more 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

Healthy, young patients with a brief duration of hematospermia, an otherwise normal history and examination, and no travel history likely have an idiopathic disorder.

Epididymal tenderness suggests an STD 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 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

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.

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 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 is suspected, it can be treated with trimethoprim/sulfamethoxazole or other antibiotic for 4 to 6 weeks. Because they can cause tendinopathy, fluoroquinolones should not be used for uncomplicated urinary tract infections whenever possible.

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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