Hematospermia, or hemospermia, is defined by the presence of blood in ejaculate (Pic. 1). It is usually an isolated symptom; however, it can present in association with hematuria (the presence of red blood cells (erythrocytes) in the urine), frequency, dysuria (to painful urination), and/or scrotal pain. It often invokes considerable anxiety and is frightening to the patient. Hematospermia has been regarded as a benign and self–limiting condition. It is most often due to inflammatory or infectious causes (Pic. 2). Recurrent or persistent hematospermia, however, may indicate a more serious underlying pathology, especially in patients over 40 years of age and such patients should be referred to a urologist for consultation.

Currently, the exact incidence of hematospermia is unknown due to the fact that most men do not examine their semen, and consequently do not report for consultation. Although an incidence of hematospermia has been reported as one in every 5,000 new patients presenting to urological out–patient clinics. Most often the age range of these patients is between 30 and 40 years, but men over 40 also present with this symptom.

Infection or inflammation is considered to be the main culprit in cases of hematospermia and in most cases is found to be self–limiting. Neoplasms such as benign urethral tumor or seminal vesicle malignancy can present as hematospermia . Hematospermia is usually a symptom of a urological problem (Pic. 3), however, other medical conditions or systemic diseases such as malignant hypertension, liver dysfunction, or bleeding diathesis may be the cause. The exact cause of hematospermia cannot be found in as many as 70 percent of patients.

Transrectal ultrasound (TRUS) has been found to be helpful in the diagnosis of prostatic pathologies, as well as calculi, cysts, prostatic varices, and inflammatory changes. It is also therapeutic in certain cases where cyst or abscess is drained and is found to be the cause of hematospermia. An urgent ultrasound should be organized in the case of a testicular lump, as this could be the cause of blood in the ejaculate. The MRI (magnetic resonance imaging) has also been reported as sensitive in the detection of bleeding in the seminal vesicles in patients with hematospermia. In case of recurrent hematospermia, MRI and CT (computerized tomography) may be useful in finding the cause. Any further investigations depend on the outcome of clinical evaluation.

In the majority of cases, a firm reassurance is particularly sufficient in patients with minimal risk factors aged below 40 years. The main purpose of the numerous investigations mentioned above is to exclude serious conditions such as cancer of the bladder or prostate. If the condition is found to be idiopathic, it is important to thoroughly explain the situation to the patient in detail in order to alleviate his anxiety. Hematospermia can be safely managed at the patient's primary care facility and referrals for further urological consultation regarding this matter should only be made in case of abnormal findings on examination, elevated PSA (prostate-specific antigen), and/or recurrent symptoms.

Patients with hematospermia and high–risk factors, i.e. aged over 40 years, recurrent or persistent hematospermia, hematuria, or familial history of PCa (prostate cancer), require more extensive evaluation and should be referred to a urologist for specialist consultation. However, in the absence of any obvious cause the treatment of hematospermia becomes challenging.

The prognosis relates to the underlying cause of blood in the semen if a cause can be identified. However, most cases of hematospermia are benign and resolve without treatment. While cancer is a rare cause of blood in the semen, the majority of cases are not related to cancer.

In young patients, it is almost never a sign of urological malignancy, and usually points toward a self-limiting disease, such as prostatitis, urethritis, or epididymo-orchitis. Each of these conditions may negatively impact a man's ability to contribute to conception.


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