Red flag symptoms - Haematospermia

Differentiate between haematospermia and haematuria to make an accurate diagnosis, writes Dr Elizabeth Croton - Repeated episodes

Haematospermia is a common complication of prostatic surgery
Haematospermia is a common complication of prostatic surgery
  • Age >40 years
  • Hepatosplenomegaly or renal enlargement
  • Irregular prostate on rectal examination
  • Signs of malignant hypertension

Haematospermia is the presence of macroscopic blood in the ejaculate.

It is most common between the ages of 30 and 40 years.

About a third of cases of haematospermia are idiopathic (primary), with 90% of patients having no previous genitourinary symptoms, and blood in the ejaculate as the only symptom.

Persistent cases are more likely to be associated with significant pathology. Sinister causes of haematospermia are more common over the age of 40 years.

History

It is important to distinguish between haematospermia and haematuria, because both conditions may coexist in some patients. In addition, the amount of bleeding, duration, colour and frequency of symptoms should be ascertained.

A history of painful ejaculation, perineal pain or associated lower urinary tract symptoms might suggest infective or obstructive causes. A sexual history should be taken to ascertain risk of STI.

Recent overseas travel may suggest tropical disease. Systemic features, such as weight loss, lymphadenopathy or abdominal symptoms, may indicate malignancy. Haematospermia is a recognised symptom following prostatic surgery.

Possible causes
Primary
  • Idiopathic
Secondary
  • Following prostatic biopsy or transurethral resection of prostate
  • Prostatic malignancy
  • Prostatitis/epididymitis/seminal vasculitis
  • Urinary calculi
  • Urethral stricture
  • Ejaculatory duct cysts
  • Perineal or testicular trauma
  • Arterial hypertension
  • Clotting disorder, such as haemophilia
  • Schistosomiasis
  • Urethral condylomata

Examination

The examination should involve the abdomen to look for hepatosplenomegaly, any masses and palpable bladder. Additionally, examine the genitalia, spermatic cord and penile urethra for any inflammatory or neoplastic pathology. A rectal examination is mandatory to examine the prostate gland.

Tenderness may indicate infection, whereas an irregular surface or nodules may indicate malignancy.

The skin should be examined for bruising, which might indicate a coagulopathy. BP should be checked, as haematospermia is a rare complication of malignant hypertension.

Investigations

Investigations include urine collection (before and after prostatic massage) and semen culture. Urine samples can be useful in patients with a high-risk sexual history, with urethral swabs if there is penile discharge. Microscopy and culture of urine will reveal infection or haematuria. PSA testing in patients with a prostate that feels abnormal should be carried out before referral. FBC and clotting studies are helpful in patients with suspected coagulopathy.

Who to refer

  • Men aged <40 with more then three episodes of haematospermia or if episodes continue for more than one month.
  • Men aged >40 with one episode of haematospermia.
  • Abnormal prostate on rectal examination, or signs or symptoms suggestive of malignancy.
  • Suspected malignant hypertension, tropical disease or new onset coagulopathy.

Dr Elizabeth Croton is a GP in Birmingham

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