Clinical Solutions - Haematospermia

The case A 30-year-old man presents having had one episode of haematospermia.

An ultrasound may be necessary (Photograph: SPL)
An ultrasound may be necessary (Photograph: SPL)

What causes haematospermia in this age group?
In men younger than 40 years, haematospermia is usually caused by a benign disorder, such as seminal vesicle calculi or seminal vesicle cysts.

Serious causes are rare in this age group but when they occur they are usually caused by an STI or testicular cancer. Occasionally haematospermia may be caused by severe hypertension or coagulation disorders.

What clinical assessment should I make?
Ask about the number of episodes of haematospermia (a serious cause is more likely if episodes are recurrent and prolonged), trauma to the genitalia, known bleeding disorders, symptoms of urological infection and symptoms of disorders that can cause an acquired bleeding disorder, such as liver or kidney failure.

Check the BP, look for signs of anaemia and bruising that might indicate an acquired bleeding disorder and examine the penis, testes and abdomen.

What investigations should I arrange?
Send an MSU sample for analysis and culture. If the patient is otherwise well, no other investigations are required. Arrange investigations for an STI if the patient is at risk or has symptoms. Arrange an FBC, coagulation screen, renal tests and LFTs if there are signs of a bleeding disorder. Refer urgently or arrange a scrotal ultrasound if testicular swelling is present.

How do I manage the patient?
If there are no signs of an underlying cause, reassure the patient that a serious underlying cause is very unlikely and that men his age (under 40 years) usually experience only one or two self-limiting episodes of haematospermia.

If an underlying cause is identified, manage this.

When should I refer?
Refer a man under the age of 40 years with haematospermia to a urologist if he experiences more than three episodes of haematospermia or if he has a prolonged episode (that lasts longer than a month).

What if the man is 40 years of age or older?
In men 40 years and older, a serious underlying cause is more likely. The most common serious underlying causes include prostate cancer, benign prostatic hyperplasia and prostatitis.

Unless the man has had a recent prostatic biopsy, refer to a urologist for further assessment after one episode of haematospermia.

Evidence
These recommendations are based on expert opinion published in review articles1-7 and supported by limited evidence8 that the risk of a serious underlying cause is extremely low in men younger than 40 years and the risk of prostate cancer is probably increased in men 40 years of age and older.

Resources
1. Narouz N and Wallace DM. Int J STD AIDS 2002; 13(8): 517-21.

2. Papp GK, Kopa Z, Szabo F et al. Andrologia 2003; 35(5): 317-20.

3. Ahmad I, Krishna, NS. Hemospermia. J Urol 2007; 177(5): 1,613-8.

4. Magoha GA, Magoha OB. East Afr Med J 2007; 84(12): 589-94.

5. Aslam MI, Cheetham P, Miller MA. Nat Rev Urol 2009; 6(7): 398-402.

6. Stefanovic KB, Gregg PC, Soung M. Am Fam Physician 2009; 80(12): 1421-7.

7. Torigian DA, Ramchandani P. Abdom Imaging 2007; 32(1): 29-49.

8. Han M, Brannigan RE, Antenor JA et al. J Urol 2004; 172(6 Pt 1), 2,189-92.

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