Hematospermia (less commonly hemospermia) refers to the presence of blood in semen or ejaculatory fluid. It is a symptom that can cause great anxiety in patients despite usually being of benign etiology.
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Pathology
Etiology
Benign
- urogenital infections including sexually transmitted disease, including orchitis and/or epididymitis, and prostatitis
- commonest cause in patients <40 years of age
- seminal vesiculitis and urethritis rarely
- benign prostatic hyperplasia (BPH)
- trauma
- scrotal
- pelvic
- iatrogenic
- prostate instrumentation
- ejaculatory duct/seminal vesicular obstruction
- cysts
- calculi
- chronic abstinence
- systemic
- untreated severe hypertension
- bleeding diatheses
- lymphoma
- leukemia
- chronic infections e.g. tuberculosis, schistosomiasis
- amyloidosis
Malignant
- prostate cancer
- bladder cancer
- urethral cancer
- testicular cancer
- epididymal cancer (very rare)
- seminal vesicle cancer (very rare)
Radiographic features
Although imaging is frequently requested in these patients no cause is identified in most cases.
Scrotal ultrasound is commonly requested imaging test in young patients. However, transrectal ultrasound is likely to be more helpful, particularly in patients with suspected prostate malignancy.
MRI with an endorectal coil can be used for the detailed assessment of the prostate and seminal vesicles. Pelvic angiography has been used to look for vascular anomalies in a patient with persistent hematospermia without any other identifiable cause.
Treatment and prognosis
Most patients are young and have episodic symptoms that require no specific treatment.
Approach to hematospermia
The patient's age and persistence of symptoms guide the workup and subsequent treatment for hematospermia. The American College of Radiology has developed guidelines on the investigation of hematospermia to help ensure appropriate use of imaging.
Men <40 years with episodic or transient symptoms and no signs of disease
- no imaging advised
- watchful waiting, reassurance, and follow-up
Men >40 years with persistent symptoms or signs of disease
- PSA and digital rectal exam
- consider transrectal ultrasound or endorectal coil MRI
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