Robert L. Segal, MD, FRCS(C)
Arthur L. Burnett, II, MD, MBA, FACS
BASICS
DESCRIPTION
• Hematospermia (sometimes referred to as hemospermia) as the presence of visible blood (fresh or altered) in the ejaculate (not specified with regard to how many episodes or overall duration).
• Semen can be described as bright red, coffee-colored, rusty, or darkened; appearance may change as blood ages.
• May occur as a single episode or persist chronically.
• Usually a self-limited and benign condition.
EPIDEMIOLOGY
Incidence
• Accounts for 0.02% (1/5,000) new patient visits to a urology clinic; seen in 0.5% of men presenting for prostate cancer screening (1)
• Mean presenting age of 37 yr old
• Mean duration is 1–24 mo
• In men <40 yr old, cause is always almost due to an inflammatory or infectious process.
• Only 2.4–3.5% of cases of hematospermia result in the diagnosis of a malignancy, typically >40 yr old.
Prevalence
Not truly known
RISK FACTORS
• Recent genitourinary trauma, surgery (prostate biopsy), infection
• Prostatitis, bacterial
• Prolonged abstinence from or frequent ejaculation
• Use of anticoagulant medication
• Systemic coagulopathy/bleeding disorder
• Renal agenesis (associated with seminal vesicle [SV] cysts)
Genetics
None
PATHOPHYSIOLOGY
• Often occurs in isolation
• Pathophysiologic causes include:
– Inflammation and infection
– Ductal obstruction and cysts of the accessory sexual glands
– Neoplasms
– Vascular abnormalities
– Systemic factors
– Iatrogenic factors
ASSOCIATED CONDITIONS
• Nonmalignant prostatic disease (26%)
• Hypertension (HTN) (5%)
• Genital tuberculosis (TB) (1%)
• Prostate cancer (1%)
GENERAL PREVENTION
None known
DIAGNOSIS
HISTORY
• Duration and amount of bleeding
• Sexual history/frequency
– Hematospermia often associated with long periods of abstinence or after frequent ejaculation
• Associated voiding disorders
– Hematuria
– Dysuria
– Urethral discharge
– Lower urinary tract symptoms (LUTS)
• Pain (pelvic, perineal)
• Systemic symptoms:
– Fever
– Weight loss
• Travel history to endemic areas:
– TB
– Schistosomiasis
– Hydatid disease (Echinococcus)
• Medications
– Aspirin
– Oral anticoagulants
– Atomoxetine (approved for the treatment of attention deficit hyperactivity disorder [ADHD])
• Recurrent trauma, surgery, or infection:
– Transrectal ultrasound (TRUS) biopsy
– Brachytherapy
– Microwave hyper thermia
– Cryoablation
– Radiation therapy
– High-intensity focused ultrasound (HIFU)
– Sexually transmitted infection
– Vasectomy
• Medical conditions
– HTN
– Liver disease
– Bleeding disorders
– Hyperuricemia in one series
• Rule out partner as a source (ie, vaginal bleeding)
– If uncertainty exists, consider having the patient ejaculate into a condom for objective verification
PHYSICAL EXAM
• Assess blood pressure (BP)
• Abdominal exam for masses
• Penis/urethra
– Meatal lesions/masses
– Discharge
– Condylomata
– Meatus should be checked for bloody discharge after rectal exam
• Scrotum, epididymides, and testes:
– Palpate vas deferens:
Induration may indicate TB
Absence may explain infertility
– Assess for masses/fluctuance or tenderness
• Prostate
– Nodularity: Tenderness, masses
– Palpate for midline cystic structures
– SV fullness can be associated with schistosomiasis (egg burden)
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis and cultures:
– Urine culture (for acid-fast bacilli and parasites if indicated)
• Serum white cell count and coagulation profile (platelets/PT/PTT)
– Complete blood count (CBC) if blood dyscrasia
• Suspected
– INR for patients on coumadin
• Tuberculin skin test should be considered, particularly in patients with exposure history or if originate from or recent travel to endemic areas.
• Semen analysis can be used to confirm diagnosis of true hematospermia and, in cases of schistosomiasis, eggs may be noted. If performed, semen culture should also be sent.
• Urethral swabs/urine studies for the diagnosis of sexually transmitted infection if indicated
• In patients >40 yr or with risk factors for prostate or bladder malignancy:
– Prostate serum antigen (PSA)
– Urine cytology
Imaging
• Trans rectal ultrasound (TRUS) of the prostate:
– To evaluate the prostate, seminal vesicles (SV’s), and possible Müllerian duct remnants
– Identifies etiology in ∼95% of cases
Prostatic calcifications (43%)
Ejaculatory duct calculi (39%)
SV calcifications (11%)
Dilated SV (22%)
Ejaculatory duct cyst (11%)
– Facilitates diagnostic procedures such as biopsy, puncture
– Should be 1st imaging study for hematospermia
• Magnetic resonance imaging (MRI)
– Abnormal signal intensity may represent hemorrhage
– Should be used if TRUS is not diagnostic or if TRUS is equivocal
– Cross-sectional or endorectal coil MRI may be obtained
Diagnostic Procedures/Surgery
• Prostate biopsy
– Indicated if clinical suspicion of prostate cancer is high
• Cystourethroscopy
– Allows visualization of urethral inflammation and opening of ejaculatory ducts
– Critical for ruling out urothelial carcinoma
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Inflammation/infection
– Calculi of SVs, prostate, or urethra
– Prostatitis
– Urethritis
– Seminal vesiculitis
– Viral:
Herpes simplex
Cytomegalovirus
Human papilloma virus/condylomata
– Bacterial:
TB
Chlamydia trachomatis
Gonorrhea
Syphilis
– Parasitic:
Schistosomiasis
Hydatid disease (Echinococcus)
• Ductal obstruction and cysts of accessory glands:
– Ejaculatory duct cyst
– SV diverticulum
– Urethral stricture
– Utricular cysts
– Wolffian duct cysts
– Prostatic cysts
• Neoplasms:
– Benign
BPH
Leiomyoma of the SV
Urethral adenoma
– Malignant
Bladder: Urothelial carcinoma
Prostate: Adenocarcinoma, ductal adenocarcinoma, sarcoma, stromal tumor, lymphoma, malakoplakia
SV: Adenocarcinoma, sarcoma, squamous cell carcinoma, malakoplakia, metastases to prostate or SVs (metastatic melanoma to the SVs or prostate, may result in melanospermia)
Urethra
Testis
Epididymis: Mesothelioma
• Vascular abnormalities
– Arteriovenous malformations
– Prostatic varicosities
– Hemangioma
• Systemic factors
– Hematologic conditions
– Hemophilia
– Von Willebrand disease
– HTN
– Chronic liver disease
– Amyloidosis of the SVs
• Iatrogenic causes
– Prostate biopsy (most common)
– Genitourinary (GU) instrumentation
– Extracorporeal shock wave lithotripsy (ESWL) of distal ureteral stones
– Brachytherapy (occurs in 28% of seed cases)
– Prostate radiation
– HIFU
– Postvasectomy (vasovenous fistula)
– Postorchiectomy
TREATMENT
GENERAL MEASURES
• If an underlying cause is identified (ie, bleeding disorder, GU TB, schistosomiasis), initiate appropriate medical management.
• Patients should be made aware that this is very common after prostate biopsy
• Spontaneous hematospermia is rarely associated with malignancy
• Most commonly a benign condition that resolves spontaneously and reassurance is appropriate
MEDICATION
First Line
• In men <40 yr old without an obvious cause of hematospermia after workup (normal physical exam, negative urine studies):
– Reassurance and expectant management
– Empiric antibiotic therapy with doxycycline or fluoroquinolone
– Trial of 5α-reductase inhibitor (finasteride, dutasteride) for 3 mo (3)[C]
• While a similar approach can be taken in men >40 yr old, diagnostic workup should be more exhaustive and prostate biopsy should be considered if PSA or DRE indicates.
Second Line
None
SURGERY/OTHER PROCEDURES
• Prostatic calculi: Transurethral incision
• Cystoscopic resection of any lesions seen on exam
• Cyst puncture and drainage should be considered in selected cases when indicated
– Can be performed via TRUS guidance, transperineal or transurethral approaches
• Transurethral cannulation of ejaculatory ducts to perform seminal vesiculoscopy with a ureteroscope and perform therapeutic interventions (dilation, stone extraction, biopsy) has been described (2)[C]
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Patients should be reassured, as should their partners.
• A significant number of cases remain idiopathic even after a full workup.
• Hematospermia following prostate biopsy may take several months to clear.
COMPLICATIONS
N/A
FOLLOW-UP
Patient Monitoring
Follow PSA in older patients, as per prostate cancer screening recommendations
Patient Resources
N/A
REFERENCES
1. Ahmad I, Krishna NS. Hemospermia. J Urol. 2007;177:1613–1618.
2. Xing C, Zhou X, Xin L, et al. Prospective trial comparing transrectal ultrasonography and transurethral seminal vesiculoscopy for persistent hematospermia. Int J Urol. 2012;19:437–442.
3. Badawy AA, Abdelhafez AA, Abuzeid AM. Finasteride for treatment of refractory hemospermia: Prospective placebo-controlled study. Int Urol Nephrol. 2012;44:371–375.
ADDITIONAL READING
• Kumar P, Kapoor S, Nargund V. Haematospermia—a systemic review. Ann R Coll Surg Engl. 2006;88:339–342.
• Leocadio DE, Stein BS. Hematospermia: Etiological and management considerations. Int Urol Nephrol. 2009;41:77–83.
• Szlauer R, Jungwirth A. Haematospermia: Diagnosis and treatment. Andrologia. 2008;40:120–124.
See Also (Topic, Algorithm, Media)
Prostate Biopsy, Infections and Complications
CODES
ICD9
• 286.9 Other and unspecified coagulation defects
• 601.9 Prostatitis, unspecified
• 608.82 Hematospermia
ICD10
• D68.9 Coagulation defect, unspecified
• N41.9 Inflammatory disease of prostate, unspecified
• R36.1 Hematospermia
CLINICAL/SURGICAL PEARLS
• Hematospermia is usually a benign and self-limited condition, particularly in men <40 yr old.
• Will often resolve spontaneously in all age groups.
• Work-up only indicated if persistent or if other associated symptoms (such as hematuria).
• Expected symptom following prostate biopsy and can last for several weeks.
• Treatment should be directed toward underlying cause if identified.