Evaluation and Treatment of Hematospermia



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Am Fam Physician. 2009 Dec 15;80(12):1421-1427.

  Patient information: See related handout on hematospermia, written by the authors of this article.

Hematospermia can be a distressing symptom for patients, but most cases are effectively managed by a primary care physician. Although the condition is usually benign, significant underlying pathology must be excluded by history, physical examination, laboratory evaluation, and, in select cases, other diagnostic modalities. In men younger than 40 years without risk factors (e.g., history of cancer, known urogenital malformation, bleeding disorders) and in men with no associated symptoms, hematospermia is often self-limited and requires no further evaluation or treatment other than patient reassurance. Many cases are attributable to sexually transmitted infections or other urogenital infections in men younger than 40 years who present with hematospermia associated with lower urinary tract symptoms. Workup in these patients can be limited to urinalysis and testing for sexually transmitted infections, with treatment as indicated. In men 40 years and older, iatrogenic hematospermia from urogenital instrumentation or prostate biopsy is the most common cause of blood in the semen. However, recurrent or persistent hematospermia or associated symptoms (e.g., fever, chills, weight loss, bone pain) should prompt further investigation, starting with a prostate examination and prostate-specific antigen testing to evaluate for prostate cancer. Other etiologies to consider in those 40 years and older include genitourinary infections, inflammations, vascular malformations, stones, tumors, and systemic disorders that increase bleeding risk.

Presence of blood in the semen, known as hematospermia or hemospermia, is often a frightening finding for patients. The incidence of hematospermia is difficult to quantify because most men do not observe their semen.1,2 Prevalence in clinical settings is highest in men younger than 40 years.3 Most cases of hematospermia can be appropriately managed by primary care physicians. Hematospermia is commonly benign and self-limited, especially in men younger than 40 years without risk factors and in men with no associated symptoms. These patients need minimal investigation, and they can be reassured if workup findings are negative, or treated if indicated. Patients with risk factors or associated symptoms, patients 40 years and older, and patients with persistent or recurrent hematospermia need more extensive evaluation and may need to be referred to a urologist.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Men younger than 40 years with limited episodes of hematospermia and no risk factors or associated symptoms can be evaluated for common genitourinary diseases, treated if indicated, and reassured.

C

1

Men with hematospermia who are 40 years and older, have associated symptoms, or have persistent hematospermia need more extensive evaluation, including assessment for underlying prostate cancer.

C

4

Low-volume hematospermia associated with iatrogenic etiologies is often self-limiting; therefore, observation is the most appropriate management strategy.

C

4


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Men younger than 40 years with limited episodes of hematospermia and no risk factors or associated symptoms can be evaluated for common genitourinary diseases, treated if indicated, and reassured.

C

1

Men with hematospermia who are 40 years and older, have associated symptoms, or have persistent hematospermia need more extensive evaluation, including assessment for underlying prostate cancer.

C

4

Low-volume hematospermia associated with iatrogenic etiologies is often self-limiting; therefore, observation is the most appropriate management strategy.

C

4


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

Etiology

Until recent decades, hematospermia was not considered clinically significant, and it was mostly attributed to prolonged sexual abstinence or intense sexual experiences because a precise etiology could not be determined in as many as 70 percent of patients who presented with it.35 Although prolonged sexual abstinence, excessive masturbation, and rigorous sexual intercourse are still considered causes of hematospermia,1 advancements in medical imaging and laboratory techniques have allowed physicians to determine a more precise cause in up to 85 percent of hematospermia cases, many of which are benign.6 Of specific etiologies, infectious conditions are the most common, accounting for approximately 40 percent of hematospermia cases.3,4 Other etiologies include inflammatory, neoplastic (e.g., prostate cancer, testicular cancer),7,8 iatrogenic (e.g., prostate biopsy [most common], prostate surgery, urologic instrumentation, radiation therapy, hemorrhoid injections),9  structural, systemic, and vascular causes (Table 1721).

Table 1.

Etiologies of Hematospermia and Their Typical Presentations

Etiology Typical presentation

Behavioral*

Excessive sex or masturbation

Isolated hematospermia episode triggered by particular sexual behavior

Interrupted sex

Prolonged sexual abstinence

Infectious*

Echinococcus (rare)

Irritative genitourinary symptoms; urinalysis positive for inflammation; positive microbiology findings

Gram-positive and gram-negative uropathogens

Mycobacterium tuberculosis (rare)

Schistosoma (rare)

Sexually transmitted infections: Chlamydia trachomatis; Neisseria gonorrhoeae; herpes simplex virus types 1 and 2 urethritis; urethral human papillomavirus

Inflammatory

Chemical epididymitis

Irritative genitourinary symptoms; urinalysis positive for inflammation; negative microbiology findings

Interstitial, eosinophilic, proliferative cystitis

Prostatitis

Seminal vesiculitis

Neoplastic

Benign and malignant tumors of the bladder, urethra, prostate, seminal vesicles, spermatic cord, epididymis, and testes

Abnormal findings on examination or imaging

Structural

Ectopic prostatic tissue or prostatic polyps

Voiding problems

Intraprostatic Müllerian duct remnants

Prostatic stones, cysts, benign prostatic hyperplasia

Urethral stricture, fistula, diverticula

Systemic

Amyloidosis

Hematospermia associated with systemic disease without other explanations

Bleeding disorders

Chronic liver disease

Severe uncontrolled hypertension

Trauma (iatrogenic)*

Hemorrhoid injections

Temporary hematospermia related to trauma

Penile injections

Prostate biopsy, radiation therapy, brachytherapy, microwave therapy, transurethral resection of the prostate

Urethral instrumentation

Urethral stent migration

Vascular

Arteriovenous malformations

Isolated hematospermia episode, or hematospermia associated with hematuria

Bladder neck and prostatic varices, submucosal bleeding, hemangiomas, telangiectasias


*— Most common causes of hematospermia.

Information from references 7 through 21.

Table 1.   Etiologies of Hematospermia and Their Typical Presentations

View Table

Table 1.

Etiologies of Hematospermia and Their Typical Presentations

Etiology Typical presentation

Behavioral*

Excessive sex or masturbation

Isolated hematospermia episode triggered by particular sexual behavior

Interrupted sex

Prolonged sexual abstinence

Infectious*

Echinococcus (rare)

Irritative genitourinary symptoms; urinalysis positive for inflammation; positive microbiology findings

Gram-positive and gram-negative uropathogens

Mycobacterium tuberculosis (rare)

Schistosoma (rare)

Sexually transmitted infections: Chlamydia trachomatis; Neisseria gonorrhoeae; herpes simplex virus types 1 and 2 urethritis; urethral human papillomavirus

Inflammatory

Chemical epididymitis

Irritative genitourinary symptoms; urinalysis positive for inflammation; negative microbiology findings

Interstitial, eosinophilic, proliferative cystitis

Prostatitis

Seminal vesiculitis

Neoplastic

Benign and malignant tumors of the bladder, urethra, prostate, seminal vesicles, spermatic cord, epididymis, and testes

Abnormal findings on examination or imaging

Structural

Ectopic prostatic tissue or prostatic polyps

Voiding problems

Intraprostatic Müllerian duct remnants

Prostatic stones, cysts, benign prostatic hyperplasia

Urethral stricture, fistula, diverticula

Systemic

Amyloidosis

Hematospermia associated with systemic disease without other explanations

Bleeding disorders

Chronic liver disease

Severe uncontrolled hypertension

Trauma (iatrogenic)*

Hemorrhoid injections

Temporary hematospermia related to trauma

Penile injections

Prostate biopsy, radiation therapy, brachytherapy, microwave therapy, transurethral resection of the prostate

Urethral instrumentation

Urethral stent migration

Vascular

Arteriovenous malformations

Isolated hematospermia episode, or hematospermia associated with hematuria

Bladder neck and prostatic varices, submucosal bleeding, hemangiomas, telangiectasias


*— Most common causes of hematospermia.

Information from references 7 through 21.

Evaluation

The goal of clinical assessment is to identify significant or treatable underlying causes of hematospermia.1 The foundation for a comprehensive evaluation includes a thorough patient history and physical examination. Figure 1 presents an algorithm for the evaluation of hematospermia.7,8

Hematospermia Evaluation

Figure 1.

Algorithm for the evaluation of hematospermia.

Information from references 7 and 8.

View Large

Hematospermia Evaluation


Figure 1.

Algorithm for the evaluation of hematospermia.

Information from references 7 and 8.

Hematospermia Evaluation


Figure 1.

Algorithm for the evaluation of hematospermia.

Information from references 7 and 8.

HISTORY

The first step of the history is to rule out pseudo-hematospermia (Table 2) by determining if hematuria is being misinterpreted as hematospermia or if the blood may have been from the patient's sexual partner (e.g., ask about his partner's possible menstruation or genitourinary infection, and about intense sexual behavior).1,4

Table 2.

Possible Causes of Pseudo-Hematospermia

Cause Diagnostic studies Initial management

Hematuria

Urinalysis, computed tomography–intravenous pyelogram

Treat if indicated versus urology or nephrology referral

Sexual partner source

Condom test or sperm sample from self-stimulation, if needed

Patient reassurance, if negative

Melanospermia (melanoma metastasis to prostate; very rare)

Skin examination; semen analysis with or without chromatography, if suspected

Oncology referral

Table 2.   Possible Causes of Pseudo-Hematospermia

View Table

Table 2.

Possible Causes of Pseudo-Hematospermia

Cause Diagnostic studies Initial management

Hematuria

Urinalysis, computed tomography–intravenous pyelogram

Treat if indicated versus urology or nephrology referral

Sexual partner source

Condom test or sperm sample from self-stimulation, if needed

Patient reassurance, if negative

Melanospermia (melanoma metastasis to prostate; very rare)

Skin examination; semen analysis with or without chromatography, if suspected

Oncology referral

Once true hematospermia has been confirmed, three key factors help guide further evaluation: age of the patient, duration of symptoms, and presence of associated symptoms or risk factors (Tables 3 and 4). In men younger than 40 years, risk factors of behavior-related hematospermia or infectious etiologies should be assessed. In men 40 years and older, neoplasia or structural abnormalities should be more strongly considered. Hematospermia that is limited to a few episodes usually has an identifiable etiology (e.g., infection, intense sexual experiences) and is less concerning than persistent or recurring hematospermia, which can indicate a pathologic condition.

Table 3.

Evaluation and Initial Management of Isolated Hematospermia

Differential diagnosis Diagnostic studies Initial management

First episode of hematospermia*

Excessive sex or masturbation; interrupted sex; prolonged sexual abstinence

Urinalysis

Patient reassurance, education

STI

STI testing based on risk stratification

Treat as indicated, patient education

Urinary tract infection

Urinalysis and culture

Treat as indicated, patient education

Benign prostate hyperplasia†

American Urological Association symptom index, postvoid residual

Monitoring versus pharmacologic treatment

Prostate cancer†

Prostate-specific antigen

Urology referral for prostate biopsy

Persistent, recurrent, or high-volume hematospermia

Vascular (prostate or urethral varices, hemangioma)

Urinalysis

Urology referral for fulguration

Tumors (bladder, urethra, prostate, seminal vesicles, spermatic cord, epididymis, testes)

Urinalysis, urine cytology

Urology referral

Bleeding diathesis

Prothrombin time, partial thromboplastin time, complete blood count

Treat as indicated


note: Isolated hematospermia is hematospermia with no associated symptoms or obvious etiology.

STI = sexually transmitted infection.

*— Blood in fewer than 10 consecutive ejaculations or for less than 12 weeks.

†— In patients 40 years and older.

Table 3.   Evaluation and Initial Management of Isolated Hematospermia

View Table

Table 3.

Evaluation and Initial Management of Isolated Hematospermia

Differential diagnosis Diagnostic studies Initial management

First episode of hematospermia*

Excessive sex or masturbation; interrupted sex; prolonged sexual abstinence

Urinalysis

Patient reassurance, education

STI

STI testing based on risk stratification

Treat as indicated, patient education

Urinary tract infection

Urinalysis and culture

Treat as indicated, patient education

Benign prostate hyperplasia†

American Urological Association symptom index, postvoid residual

Monitoring versus pharmacologic treatment

Prostate cancer†

Prostate-specific antigen

Urology referral for prostate biopsy

Persistent, recurrent, or high-volume hematospermia

Vascular (prostate or urethral varices, hemangioma)

Urinalysis

Urology referral for fulguration

Tumors (bladder, urethra, prostate, seminal vesicles, spermatic cord, epididymis, testes)

Urinalysis, urine cytology

Urology referral

Bleeding diathesis

Prothrombin time, partial thromboplastin time, complete blood count

Treat as indicated


note: Isolated hematospermia is hematospermia with no associated symptoms or obvious etiology.

STI = sexually transmitted infection.

*— Blood in fewer than 10 consecutive ejaculations or for less than 12 weeks.

†— In patients 40 years and older.

Relevant associated symptoms include genitourinary pain or voiding symptoms. Pain with urination may suggest urethritis, cystitis, or prostatitis, whereas pain with bladder distention usually indicates cystitis. Pain with ejaculation may be associated with prostatitis or obstruction of an ejaculatory duct. Voiding symptoms may indicate primary or secondary involvement of the bladder or bladder outlet, such as dysfunctional conditions or morphologic abnormalities. Ascertaining the patient's sexual history and history of iatrogenic injury is important because sexually transmitted infections (STIs) and instrumentation, biopsy, or other procedures are leading causes of hematospermia.

Systemic diseases that may be associated with hematospermia include bleeding disorders; liver disease, which can affect clotting factor production; and severe uncontrolled hypertension (demonstrated in a limited case-control study22), which is attributed to interference with clotting.22,23 Constitutional symptoms (e.g., weight loss, night sweats, fever, chills, bone pain) may indicate a neoplastic or infectious source. Travel and medication history also may point to a source (e.g., tuberculosis exposure, Schistosoma infection, warfarin [Coumadin] use).13

Table 4.

Evaluation and Initial Management of Hematospermia with Associated Conditions or Symptoms

Associated condition or symptom Differential diagnosis Diagnostic studies Initial management

Trauma

Self-inflicted

Abrasion

Urinalysis

Monitor

Foreign body

Urinalysis; urine culture, if indicated

Urology referral for endoscopy

Arteriovenous fistula (e.g., secondary to penile injections)

Urology referral for penile Doppler study

Iatrogenic*

Trauma, inflammation, or infection

Urinalysis; urine culture, if indicated

Monitor, anti-inflammatories or antibiotics if indicated, consider urology referral

Genitourinary infection or inflammation

Urinary tract infection or STI

Urinalysis, STI testing

Treat as indicated, consider urology referral

Prostatitis

Localization studies† with or without sperm culture

Epididymitis

Urinalysis, urine culture with or without scrotal Doppler ultrasonography

Voiding symptoms

Benign prostate hyperplasia

American Urological Association symptom index, post-void residual

Alpha blocker with or without 5-alpha reductase inhibitor

Bladder neck dysfunction

Urinalysis

Alpha blocker

Prostate cancer

Prostate-specific antigen

Urology referral

Urethral stricture

Urinalysis, post-void residual

Urology referral

Cystitis (interstitial or eosinophilic)

Urinalysis

Urology referral

Pain with ejaculation

Prostatitis

Localization studies† with or without sperm culture

Treat as indicated

Obstruction of ejaculatory duct by stones, strictures, polyps, tumors, cysts

Transrectal ultrasonography or prostate magnetic resonance imaging

Urology referral

Systemic disorders

Hypertension

Blood pressure, serum creatinine, urinalysis with protein quantification

Treat underlying disorder

Bleeding disorder

Prothrombin time, partial thromboplastin time, CBC

Malignancy (leukemia, lymphoma)

CBC with differential

HIV, immunosuppression

HIV screening, purified protein derivative

Liver disease

Complete metabolic panel, hepatitis panel

Travel or exposure history

Tuberculosis

Purified protein derivative testing, urine acid-fast bacillus, chest radiography

Treat as indicated, or infectious disease referral

Schistosomiasis

Computed tomography–intravenous pyelogram; urine, semen, and stool analysis for Schistosoma


CBC = complete blood count; HIV = human immunodeficiency virus; STI = sexually transmitted infection.

*— Includes prostate biopsy (most common), prostate surgery, urologic instrumentation, radiation therapy, or hemorrhoid injections.

†— Localization of the site of infection requires four fluid samples: first void, midstream void, expelled prostatic secretions, and post-prostatic massage void.

Table 4.   Evaluation and Initial Management of Hematospermia with Associated Conditions or Symptoms

View Table

Table 4.

Evaluation and Initial Management of Hematospermia with Associated Conditions or Symptoms

Associated condition or symptom Differential diagnosis Diagnostic studies Initial management

Trauma

Self-inflicted

Abrasion

Urinalysis

Monitor

Foreign body

Urinalysis; urine culture, if indicated

Urology referral for endoscopy

Arteriovenous fistula (e.g., secondary to penile injections)

Urology referral for penile Doppler study

Iatrogenic*

Trauma, inflammation, or infection

Urinalysis; urine culture, if indicated

Monitor, anti-inflammatories or antibiotics if indicated, consider urology referral

Genitourinary infection or inflammation

Urinary tract infection or STI

Urinalysis, STI testing

Treat as indicated, consider urology referral

Prostatitis

Localization studies† with or without sperm culture

Epididymitis

Urinalysis, urine culture with or without scrotal Doppler ultrasonography

Voiding symptoms

Benign prostate hyperplasia

American Urological Association symptom index, post-void residual

Alpha blocker with or without 5-alpha reductase inhibitor

Bladder neck dysfunction

Urinalysis

Alpha blocker

Prostate cancer

Prostate-specific antigen

Urology referral

Urethral stricture

Urinalysis, post-void residual

Urology referral

Cystitis (interstitial or eosinophilic)

Urinalysis

Urology referral

Pain with ejaculation

Prostatitis

Localization studies† with or without sperm culture

Treat as indicated

Obstruction of ejaculatory duct by stones, strictures, polyps, tumors, cysts

Transrectal ultrasonography or prostate magnetic resonance imaging

Urology referral

Systemic disorders

Hypertension

Blood pressure, serum creatinine, urinalysis with protein quantification

Treat underlying disorder

Bleeding disorder

Prothrombin time, partial thromboplastin time, CBC

Malignancy (leukemia, lymphoma)

CBC with differential

HIV, immunosuppression

HIV screening, purified protein derivative

Liver disease

Complete metabolic panel, hepatitis panel

Travel or exposure history

Tuberculosis

Purified protein derivative testing, urine acid-fast bacillus, chest radiography

Treat as indicated, or infectious disease referral

Schistosomiasis

Computed tomography–intravenous pyelogram; urine, semen, and stool analysis for Schistosoma


CBC = complete blood count; HIV = human immunodeficiency virus; STI = sexually transmitted infection.

*— Includes prostate biopsy (most common), prostate surgery, urologic instrumentation, radiation therapy, or hemorrhoid injections.

†— Localization of the site of infection requires four fluid samples: first void, midstream void, expelled prostatic secretions, and post-prostatic massage void.

PHYSICAL EXAMINATION

Elevated blood pressure, fever, and tachycardia may indicate a systemic cause, such as severe uncontrolled hypertension, infection, or malignancy. Detailed abdominal and genitourinary examinations should be performed to assess for trauma, inflammation, discharge, and lymphadenopathy. Full scrotal examination is important to evaluate for inflammation; infection; and masses of the testes, epididymis, and spermatic cords.14 Rectal examination is needed to check the prostate for size, tenderness, fluctuation, symmetry, firmness, and nodularity.1,3

FURTHER TESTING

Usually, hematospermia has resolved by the time a patient sees his physician. If the patient has no risk factors or associated symptoms, he should be reassured that such self-limited hematospermia needs no further evaluation or treatment. However, in most patients with ongoing lower urinary tract symptoms, urinalysis should be performed and testing for genitourinary infections, including STIs, should be considered (Table 3).

Minimal, directed laboratory evaluation usually leads to a diagnosis, and patients often have quick resolution with treatment. However, certain associated symptoms and laboratory findings require prompt subspecialty referral and intervention (Table 5). For example, if results of the prostate examination are abnormal or if the prostate-specific antigen level is elevated, a prostate biopsy is indicated to evaluate for malignancy. Urology referral should also be considered for a patient whose history, physical examination, and initial laboratory workup do not lead to a diagnosis, yet hematospermia persists or recurs. Urologists use several additional tools to evaluate patients with hematospermia, including urethrocystoscopy, transrectal ultrasonography with or without Doppler vascular evaluation, scrotal ultrasonography, magnetic resonance imaging, and computed tomography.1,3,19,24

Table 5.

Indications for Hematospermia Urology Referral

Based on symptoms:

Hematospermia associated with genitourinary pain

Hematospermia associated with unexplained voiding symptoms

Recurrent, persistent, high-volume hematospermia

Based on evaluation:

Abnormal examination findings suggestive of tumor or structural problems

Abnormal prostate-specific antigen findings

Abnormal urinalysis findings (hematuria, sterile pyuria)

Suspected foreign body, stent migration

Suspected vascular malformation

Based on lack of response to initial management:

Symptoms or abnormal findings persist

Table 5.   Indications for Hematospermia Urology Referral

View Table

Table 5.

Indications for Hematospermia Urology Referral

Based on symptoms:

Hematospermia associated with genitourinary pain

Hematospermia associated with unexplained voiding symptoms

Recurrent, persistent, high-volume hematospermia

Based on evaluation:

Abnormal examination findings suggestive of tumor or structural problems

Abnormal prostate-specific antigen findings

Abnormal urinalysis findings (hematuria, sterile pyuria)

Suspected foreign body, stent migration

Suspected vascular malformation

Based on lack of response to initial management:

Symptoms or abnormal findings persist

Treatment

If treatment is necessary, it should be directed at the diagnosed etiology. Appropriate antibiotics are indicated in patients with genitourinary infection. If infection is suspected, yet none is found, empiric two-week treatment with an antibiotic that penetrates the prostate-blood barrier (e.g., fluoroquinolones, doxycycline, trimethoprim, trimethoprim/sulfamethoxazole [Bactrim, Septra]) may be beneficial, with follow-up if symptoms recur or persist.1 Iatrogenic causes of hematospermia usually resolve spontaneously within a few weeks or approximately 10 ejaculations.4,9,2527 Other treatments for hematospermia are usually initiated under the direction of a urologist, and include transurethral endoscopic resection, incision, fulguration, or marsupialization.1,16,18,19,21

Monitoring and Referral

Most men with an easily treatable cause of hematospermia do not need follow-up. Men with recurrent or persistent isolated hematospermia or symptomatic men in whom an etiology is not elucidated require follow-up within three to six months to reassess symptoms and potential etiologic factors. Poor response to treatment or troublesome associated symptoms or findings should prompt referral to a urologist (Table 5).

The Authors

KSENIJA B. STEFANOVIC, MD, PhD, is an assistant clinical professor in the Department of Urology at the University of Washington School of Medicine in Seattle. She is a staff urologist at Virginia Mason Medical Center, Seattle, Washington.

PETER C. GREGG, MD, MPH, is a resident in internal medicine-primary care at Virginia Mason Medical Center.

MICHAEL SOUNG, MD, is an assistant program director in the Department of General Internal Medicine at Virginia Mason Medical Center.

Address correspondence to Ksenija B. Stefanovic, MD, PhD, Dept. of Urology, Virginia Mason Medical Center, 1100 Ninth Ave., Mailstop C7-URO, Seattle, WA 98101 (e-mail: ksenija.stefanovic@vmmc.org). Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

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