Hematospermia: Benign or cause for Concern?

In primary care practice, repetition is a common theme among my day to day activities. This allows me to get into a groove with prescribing medications, diagnosing conditions that I see commonly, but can be difficult for cases that I do not see frequently.

Ask me to name and discuss all of the medications used to treat diabetes and I’m confident, but ask me to discuss the work up and evaluation for a condition I may only see a few times per year, well, that is more difficult.

Today, we will focus on one of these: hematospermia or the presence of blood in the semen.

I have yet to have a patient encounter regarding blood in the semen that has not been anxiety and stress fueled. For the vast majority of patients, this is a very unnerving condition and patients are usually very worried as part of the visit.

They may have also spent some time on the internet, looking up their symptoms and finding that they are very concerned about cancer. As part of the health care team, we can sometimes forget how real this fear can be, so it is important to take these visits cautiously and with great empathy.

 

What should you ask?

Hematospermia, as mentioned above, is the presence of gross blood in the semen, or a blood tinged semen (Weiss, 2019). Although it is very concerning to patients, it is almost always a result of a benign process. Today, we will review hematospermia in depth and the goal will be to allow clinicians to become comfortable with the work up of this rare, but important condition.

This condition is particularly rare, making up about 1% of all urologic complaints (Mathers, 2017). It’s estimation of prevalence is about 1 in 5000 patients seen in urology offices. The first step for the evaluating clinician is to obtain more information.

  • How long has it been present?
  • How many times has it happened?
  • What color is the blood? (this is important)
  • Were there associated symptoms (pain, dysuria, difficulty voiding).
  • Does the patient have underlying BPH or prostate cancer?
  • Has the patient had any recent urologic procedure?
  • Is there personal/family history of a clotting disorder?

Evaluation of the frequency, amount, and color of the ejaculate may be difficult for patients to discuss, but it is important to help guide the clinician. Blood that is fresh may appear red while blood that has had more time to clot may appear darker or even black.

Obtaining a good history via the OPQRST method is helpful as well as assessing for associated symptoms that may clue in to a particular diagnosis.

For example, in a young patient with multiple sexual partners, hematospermia in the setting of dysuria, penile discharge is concerning for STI. In an older patient with frequency, urgency, nocturia, this maybe concerning for BPH or prostate cancer. (Weiss, 2019).

A good sexual history is important as well, as the clinician must be able to rule out sexually transmitted infection as a possible cause. Obtaining the number, frequency, and method of intercourse is important to help risk stratify. Family history of prostate cancer, blood disorder such as von willebrand’s disease is also helpful. A thorough surgical history may also reveal recent procedure.

 

Differential diagnosis for hematospermia

Determining the cause of hematospermia is difficult, as the possible etiologies are numerous. The most common cause of hematospermia is recent prostate biopsy (Weiss, 2019). Patients undergoing prostate biopsy should be notified that they can possibly have blood in the semen for up to a month post procedure. Vasectomy and radiation therapy for prostate cancer treatment are also important causes. Other causes are numerous and include:

  • Infectious (Gonorrhea, Chlamydia, HSV, Trichomonas, Schistomiasis)
  • Cancer (Prostate, bladder, metastatic melanoma or renal cell cancer, testicular)
  • Prostate disorders (BPH, prostate cancer, prostatitis, prostate polyp, etc).
  • Dilated seminal vesicle, epididymitis, amyloidosis, Von Willebrand’s, hyperuricemia
  • Idiopathic (up to 70% may not have a determined cause).

It is important to note that there is a very low chance of any concerning clinical entity in patients less than 40 years old and despite the concern, it is almost always benign in nature.

 

Evaluating the cause

Standard evaluation for patients with hematospermia, regardless of their age at presentation, including the History and Physical as well as a urinalysis. A urinalysis can give information in regards to urinary tract infection. Patients with concern for sexually transmitted diseases should be tested for gonorrhea as well as chlamydia. Persistent hematuria and urethritis symptoms despite negative testing warrants evaluation for trichomonas.

Semen analysis is usually not necessary as part of routine work up. In cases where schistosomes are considered in the differential, it may be useful, but is not routinely recommended otherwise.

According to UpToDate, prostate specific antigen testing is controversial and generally not recommended for patients under age 50 (Weiss, 2019). For patients over 50, a PSA is reasonable as part of routine screening and to evaluate for prostatic disorders that may be influencing the symptoms.

The imaging test of choice, if necessary is the transrectal ultrasound. Guidelines suggest that if hematospermia is present for greater than one month, this be the first step taken as part of imaging. For many providers, this would also be a referral to a urologist.

The transrectal ultrasound is excellent for evaluation of the rectum, prostate, seminal vesicles, and other structures (Weiss, 2019). Other ancillary tests performed by the urologic specialist may include a cystoscopy, testicular ultrasound, or prostate biopsy.

 

Treating hematospermia

The treatment for hematospermia depends on the underlying etiology. In males under 40 without evidence for infectious origin, simple monitoring is usually sufficient. Hematospermia that persists longer than one month should be referred to a urologist.

In men greater than 50 with risk factors for prostate cancer, referral should be made to discuss the various options. Gonorrhea and chlamydia are treated with antibiotics.

There is really no evidence to recommend treating for presumptive prostatitis, unless other comorbid symptoms support a diagnosis of prostatitis.

The vast majority of these cases of hematospermia do end up resolving spontaneously, so reassurance is usually sufficient. In men greater 50, a thorough work up through an experienced urologist should be attained.

References

Mathers, M.J, Degener,S, Sperling, H., and Roth, S. (2017). Hematospermia: A symptom with many possible causes. Dtsch Arztbel 114, (11), p 186-191.

Weiss, B.D. and Richie, J.P. (2019). Hematospermia. UpToDate. Date of Access 10 September 2019.