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Hematospermia Clinical Presentation

  • Author: Jonathan D Schiff, MD; Chief Editor: Edward David Kim, MD, FACS  more...
Updated: Jul 24, 2016


A good patient history that concentrates on pelvic instrumentation, trauma, infection, and bleeding disorders often helps to narrow the differential diagnoses associated with hematospermia.

Most patients have more than one episode, occurring over weeks to months. While no uniformly accepted definition of chronic hematospermia has been determined, blood in the ejaculate that persists for more than 10 ejaculations requires further evaluation. While some authorities use duration (ie, months) as a guideline, the discrepancy in the frequency of ejaculations among men renders this approach less reliable.

Patient age is important. In patients younger than 40 years, urogenital infections are the most common cause of hematospermia, and a simple, focused workup is often sufficient. In men older than 40 years with persistent hematospermia or associated symptoms such as hematuria, excluding urogenital malignancy is essential.[3]



The physical examination should include measuring the patient's blood pressure, because severe hypertension is associated with hematospermia.[7] This association is well recognized; however, the exact mechanism by which it occurs is unclear. It may have a similar basis to the association of hypertension with epistaxis (nosebleeds).

Consider the following in the genital examination:

  • The penis should be carefully inspected to rule out any lesions that may bleed and contribute to the ejaculate.
  • The vasa should be palpated along their entire course to ensure their presence and to rule out any induration or nodularity. Any nodularity in the absence of prior vasal surgery (including vasectomy) should raise concern for a tuberculous infection of the vasa. Alternatively, nodules within the vas rarely represent extension of prostatic or bladder malignancies.
  • Upon digital rectal examination (DRE), special attention should be given to the seminal vesicles and the presence of any midline masses. The seminal vesicles are routinely nonpalpable structures. If they are palpable, this generally indicates significant underlying pathology. In older men (>50 y), specific attention should also be given to the prostate because hematospermia is occasionally a harbinger of prostate cancer.


Hematospermia is usually associated with inflammatory conditions of the seminal vesicles or prostate. The condition is often self-limited and resolves within 1-2 months. If hematospermia persists beyond 2 months, further workup is recommended to determine the cause. In approximately half the cases, the etiology is declared idiopathic. However, this may reflect an incomplete evaluation.

Conditions of the prostate

Lesions of the prostate account for many cases of hematospermia. The most common etiology is prostate biopsy, which produces self-limited hematospermia that resolves within approximately 1 month. In one case series, prostatitis was cited as the etiology in 30% of the patients.

Other authors have recognized prostate cancer as an etiologic factor. Malignancies account for 2% of cases. In a long-term follow-up study of 150 patients with hematospermia, only six patients eventually developed prostate carcinoma, and none had prostate carcinoma diagnosed at the time of the initial evaluation.

However, a study by Han et al reported a significantly increased risk of prostate cancer among men with hematospermia. Of 139 men with hematospermia, 19 (13.7%) were diagnosed with prostate cancer. In the overall cohort of 26,126 patients, the prostate cancer detection rate was 6.5%. On logistic regression analysis, the presence of hematospermia was a significant predictor of prostate cancer diagnosis.[8]

This is still a controversial area of investigation. Prando reported on a series of 86 men with hemospermia and found prostate cancer in only one patient.[9] In a review by Ng et al of 300 consecutive cases of hematospermia, 13 prostate cancers were detected (5.7%), all in men over 40 years of age with either with a prostate-specific antigen (PSA) level of >3.0 ng/dL or an abnormal digital rectal examination (DRE). Those researchers recommended screening for prostate cancer in men over 40 who present with hematospermia.[10]

Hematospermia can also be caused by prostatic telangiectasia and varices. In rare cases, a patient with hematospermia may be diagnosed with prostatic varices only after cystoscopic examination while the patient has an erection. In order to diagnose this condition, flexible (preferably) or rigid cystoscopy is conducted after pharmacological induction of an erection.

Prostatitis is often thought to cause hematospermia, although no specific association has been reported. Upon signs and symptoms of acute bacterial prostatitis, specific treatment is indicated. If symptoms of chronic pelvic pain prostatitis syndrome are present, urine culture and then culture of expressed prostatic secretions should be performed. Hematospermia is not a recognized symptom of chronic prostatitis syndrome.

In a study of 52 patients with hematospermia, Etherington et al found a significant number of patients with prostatic calculi.[11]

Another publication reported on cystic dilation of the prostatic utricle in association with hematospermia. Furuya and Kato reported on 30 of 138 men with hematospermia who had a midline cyst of the prostate. Nineteen men underwent transperineal biopsy; hemorrhagic fluid was confirmed in 13 of the men. Four of the men were cured with transurethral unroofing.[12]

With the advent of TRUS-guided prostate biopsy for the diagnosis of prostate cancer, a new etiology of hematospermia has emerged. Many centers have reviewed their experience with this complication.[13]

The rate of hematospermia following transrectal biopsy of the prostate has varied from 9-45%. In one study, 25% of patients who underwent TRUS biopsy had concomitant hematospermia and hematuria after the procedure. Berger et al reported on 5957 biopsies performed in 4303 men. This group found that hematospermia occurred after approximately 36% of the biopsies. They concluded that, in this situation, the hematospermia is generally self-limited and requires no specific therapy.[6]

Transurethral resection of the prostate is also associated with subsequent hematospermia. A study by Shen et al described 80 consecutive men who underwent transurethral prostate resection and found that hematospermia developed in 2.5% of the men.[14]

Some authors have recommended administering finasteride beginning 2 weeks prior to TRUS biopsy of the prostate to reduce the risk of postprocedure hematuria. While no studies have specifically examined the impact of finasteride on the occurrence of hematospermia, this condition may be improved with the use of this medication.

Brachytherapy as treatment for prostate cancer involves inserting radioactive seeds directly into the prostate. This procedure has been shown to cause hematospermia in up to 17% of patients who undergo this treatment.[15]

Conditions of the urethra

Urethritis has long been recognized as a cause of hematospermia, especially in younger men.

Other urethral lesions leading to hematospermia include cysts, polyps, condylomata, and strictures. Benign urethral polyps can occur following failure of the invagination process of the prostatic glandular epithelium. In one case series, 20% of patients with urethral polyps had hematospermia as their presenting symptom. In another study, urethritis, condylomata, and stricture disease represented the cause of hematospermia in 7%, 1.5%, and 1.5% of the patients, respectively.

Seminal vesicle lesions

Many authors have cited congenital and acquired seminal vesicle cysts as a cause of hematospermia. Congenital cysts result from an error in embryological development and are associated with ipsilateral renal agenesis and/or ipsilateral congenital absence of the vas deferens.

Acquired seminal vesicle cysts generally result from infectious processes, and malignancies of the seminal vesicles are a rare cause of hematospermia. In one review of 39 patients with primary carcinoma of the seminal vesicle, only 6 patients (16%) had hematospermia.

More recently, amyloidosis of the seminal vesicles has been described to be related to hematospermia.[16] Fifty-six men with hematospermia were evaluated with MRI, and obvious intravesicular hemorrhage was associated with hyperintense signal (brighter) of the seminal vesicles on MRI. After resolution of the bleeding, the signal returned to a hypointense state (lighter) on MRI. Twelve of these patients underwent transperineal biopsy; four were found to have seminal vesicle amyloidosis. In all cases, hematospermia resolved with conservative intervention.

The most recent data suggest that seminal vesicle and ejaculatory duct cysts or hemorrhagic lesions account for most identifiable causes of hemospermia. Fifty-two of 86 men in a recent study were found to have lesions in association with hemospermia. Of these men, 51 had some type of seminal vesicle, ejaculatory duct, or prostatic benign or hemorrhagic lesion. Only one case of prostate cancer was identified.[9]


Infections and inflammatory disorders account for 40% of cases. Infectious causes of hematospermia include tuberculosis (TB), HIV infection, and cytomegalovirus infection.[17] Yu and colleagues found that 11% of a cohort of 65 patients with genitourinary TB had hematospermia during their disease.[18]

A review of 16 men with hematospermia who presented to a sexually transmitted infection clinic found pathogens in 12 of the men. These included urine, genitourinary, or serum cultures or titers positive for herpes simplex virus in five, Chlamydia trachomatis in four, Enterococcus faecalis in two, and Ureaplasma urealyticum in one. Culture-specific antibiotics were administered, and hematospermia resolved in all the patients.[19]

Genitourinary schistosomiasis has been reported as a cause of hematospermia.[20] Although these patients often have extensive bladder involvement, Schistosoma hematobium ova are only occasionally found in the ejaculate.

Hydatid disease, a parasitic infection caused by the Echinococcus worm, has also been associated with hematospermia.[21]


Trauma has been cited as a cause of hematospermia in several case reports. Such case reports include hematospermia occurring following hemorrhoidal sclerosing injection, urethral self-instrumentation, and testicular and perineal blunt trauma. Hematospermia following transrectal prostate needle biopsy should also be included in this category. Approximately 2% of cases are believed to result from trauma other than that related to recent prostate biopsy.

Systemic disorders

Systemic disorders that are associated with hematospermia include hypertension, chronic liver disease, amyloidosis, lymphoma, and bleeding diatheses (eg, von Willebrand disease[22, 23] ). In one case-controlled study of patients undergoing hypertension therapy, the prevalence of hematospermia was no higher than in the general population; however, hematospermia resolved in several patients when their hypertension was controlled.

Risk factors for hematospermia in patients who are hypertensive include the following:

  • Severe uncontrolled hypertension
  • Elevated serum creatinine levels
  • Severe proteinuria
  • Renovascular disease

Kurkar and colleagues identified hyperuricemia as a possible cause of hematospermia. Compared with their patients who had idiopathic hematospermia, those with hyperuricemia (median serum uric acid level, 9.3 mg/dL) were significantly younger (median of 31.5 vs 45 years) and more likely to complain of painful ejaculation (68.2% vs 9.5%).Hematospermia resolved completely in all patients of the hyperuricemia group in 1-4 months, compared with only 25% of the idiopathic group.[24]

Contributor Information and Disclosures

Jonathan D Schiff, MD Assistant Clinical Professor of Urology, Department of Urology, Mount Sinai Medical Center; Adjunct Assistant Clinical Professor of Urology, Weill-Cornell School of Medicine

Jonathan D Schiff, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.


from Memorial Sloan-Kettering – John P Mulhall, MD Director, Sexual and Reproductive Medicine Program, Memorial Sloan-Kettering Cancer Center

from Memorial Sloan-Kettering – John P Mulhall, MD is a member of the following medical societies: American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Society for Basic Urologic Research, Society of University Urologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Additional Contributors

Edmund S Sabanegh, Jr, MD Chairman, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation

Edmund S Sabanegh, Jr, MD is a member of the following medical societies: American Medical Association, American Society of Andrology, Society of Reproductive Surgeons, Society for the Study of Male Reproduction, American Society for Reproductive Medicine, American Urological Association, SWOG

Disclosure: Nothing to disclose.

  1. Fletcher MS, Herzberg Z, Pryor JP. The aetiology and investigation of haemospermia. Br J Urol. 1981 Dec. 53(6):669-71. [Medline].

  2. Leary FJ, Aguilo JJ. Clinical significance of hematospermia. Mayo Clin Proc. 1974 Nov. 49(11):815-7. [Medline].

  3. Ahmad I, Krishna NS. Hemospermia. J Urol. 2007 May. 177(5):1613-8. [Medline].

  4. Ganabathi K, Chadwick D, Feneley RC, et al. Haemospermia. Br J Urol. 1992 Mar. 69(3):225-30. [Medline].

  5. Aslam MI, Cheetham P, Miller MA. A management algorithm for hematospermia. Nat Rev Urol. 2009 Jul. 6(7):398-402. [Medline].

  6. Berger AP, Gozzi C, Steiner H, et al. Complication rate of transrectal ultrasound guided prostate biopsy: a comparison among 3 protocols with 6, 10 and 15 cores. J Urol. 2004 Apr. 171(4):1478-80; discussion 1480-1. [Medline].

  7. Ambakederemo TE, Dodiyi-Manuel ST, Ebuenyi ID. Bloody semen, severe hypertension and a worried man. Pan Afr Med J. 2015. 20:326. [Medline].

  8. Han M, Brannigan RE, Antenor JA, et al. Association of hemospermia with prostate cancer. J Urol. 2004 12. 172(6, Part 1 of 2):2189-2192. [Medline].

  9. Prando A. Endorectal magnetic resonance imaging in persistent hemospermia. Int Braz J Urol. 2008 Mar-Apr. 34(2):171-7; discussion 177-9. [Medline].

  10. Ng YH, Seeley JP, Smith G. Haematospermia as a presenting symptom: outcomes of investigation in 300 men. Surgeon. 2013 Feb. 11(1):35-8. [Medline].

  11. Etherington RJ, Clements R, Griffiths GJ, et al. Transrectal ultrasound in the investigation of haemospermia. Clin Radiol. 1990 Mar. 41(3):175-7. [Medline].

  12. Furuya S, Kato H. A clinical entity of cystic dilatation of the utricle associated with hemospermia. J Urol. 2005 Sep. 174(3):1039-42. [Medline].

  13. Abdelkhalek MA, Abdelshafy M, Elhelaly HA, El Nasr MK. Hemospermia after transrectal ultrasound (TRUS)-guided prostatic biopsy: a prospective study. J Egypt Soc Parasitol. 2012 Apr. 42(1):63-70. [Medline].

  14. Shen BY, Chang PL, Lee SH, Chen CL, Tsui KH. Complications following combined transrectal ultrasound-guided prostate needle biopsies and transurethral resection of the prostate. Arch Androl. 2006 Mar-Apr. 52(2):123-7. [Medline].

  15. Finney G, Haynes AM, Cross P, et al. Cross-sectional analysis of sexual function after prostate brachytherapy. Urology. 2005 Aug. 66(2):377-81. [Medline].

  16. Furuya S, Masumori N, Furuya R, et al. Characterization of localized seminal vesicle amyloidosis causing hemospermia: an analysis using immunohistochemistry and magnetic resonance imaging. J Urol. 2005 Apr. 173(4):1273-7. [Medline].

  17. Koment RW, Poor PM. Infection by human cytomegalovirus associated with chronic hematospermia. Urology. 1983 Dec. 22(6):617-21. [Medline].

  18. Yu HH, Wong KK, Lim TK, et al. Clinical study of hemospermia. Urology. 1977 Dec. 10(6):562-3. [Medline].

  19. Bamberger E, Madeb R, Steinberg J, et al. Detection of sexually transmitted pathogens in patients with hematospermia. Isr Med Assoc J. 2005 Apr. 7(4):224-7. [Medline].

  20. Shebel HM, Elsayes KM, Abou El Atta HM, Elguindy YM, El-Diasty TA. Genitourinary schistosomiasis: life cycle and radiologic-pathologic findings. Radiographics. 2012 Jul-Aug. 32 (4):1031-46. [Medline].

  21. Whyman MR, Morris DL. Retrovesical hydatid causing haemospermia. Br J Urol. 1991 Jul. 68(1):100-1. [Medline].

  22. Lemesh RA. Case report: recurrent hematuria and hematospermia due to prostatic telangiectasia in classic von Willebrand's disease. Am J Med Sci. 1993 Jul. 306(1):35-6. [Medline].

  23. Minardi D, Scortechini AR, Milanese G, Leoni P, Muzzonigro G. Spontaneous recurrent hematuria and hematospermia: Unique manifestations of von Willebrand disease type I. Case report. Arch Ital Urol Androl. 2016 Mar 31. 88 (1):62-3. [Medline].

  24. Kurkar A, Elderwy AA, Awad SM, Abulsorour S, Aboul-Ella HA, Altaher A. Hyperuricemia: a possible cause of hemospermia. Urology. 2014 Sep. 84(3):609-12. [Medline].

  25. Smith GW, Griffith DP, Pranke DW. Melanospermia: an unusual presentation of malignant melanoma. J Urol. 1973 Sep. 110(3):314-6. [Medline].

  26. Xing C, Zhou X, Xin L, Hu H, Li L, Fang J, et al. Prospective trial comparing transrectal ultrasonography and transurethral seminal vesiculoscopy for persistent hematospermia. Int J Urol. 2012 May. 19(5):437-42. [Medline].

  27. Worischeck JH, Parra RO. Chronic hematospermia: assessment by transrectal ultrasound. Urology. 1994 Apr. 43(4):515-20. [Medline].

  28. Raviv G, Laufer M, Miki H. Hematospermia--the added value of transrectal ultrasound to clinical evaluation: is transrectal ultrasound necessary for evaluation of hematospermia?. Clin Imaging. 2013 Sep-Oct. 37(5):913-6. [Medline].

  29. Maeda H, Toyooka N, Kinukawa T, et al. Magnetic resonance images of hematospermia. Urology. 1993 May. 41(5):499-504. [Medline].

  30. Yang SC, Rha KH, Byon SK, et al. Transutricular seminal vesiculoscopy. J Endourol. 2002 Aug. 16(6):343-5. [Medline].

  31. Oh TH, Seo IY. Endoscopic Treatment for Persistent Hematospermia: A Novel Technique Using a Holmium Laser. Scand J Surg. 2015 Oct 22. 16:270-1. [Medline].

  32. Fuse H, Sumiya H, Ishii H, et al. Treatment of hemospermia caused by dilated seminal vesicles by direct drug injection guided by ultrasonography. J Urol. 1988 Nov. 140(5):991-2. [Medline].

  33. Li L, Jiang C, Song C, et al. Transurethral endoscopy technique with a ureteroscope for diagnosis and management of seminal tracts disorders: a new approach. J Endourol. 2008 Apr. 22(4):719-24. [Medline].

  34. Li YF, Liang PH, Sun ZY, Zhang Y, Bi G, Zhou B, et al. Imaging diagnosis, transurethral endoscopic observation, and management of 43 cases of persistent and refractory hematospermia. J Androl. 2012 Sep. 33(5):906-16. [Medline].

  35. Close CF, Yeo WW, Ramsay LE. The association between haemospermia and severe hypertension. Postgrad Med J. 1991 Feb. 67(784):157-8. [Medline].

  36. Collins GN, Lloyd SN, Hehir M, et al. Multiple transrectal ultrasound-guided prostatic biopsies--true morbidity and patient acceptance. Br J Urol. 1993 Apr. 71(4):460-3. [Medline].

  37. Craig SR. 3-in-1' nerve block complicated by haemospermia. Br J Clin Pract. 1992 Summer. 46(2):80. [Medline].

  38. Geoghegan JG, Bonavia I. Haemospermia as a presenting symptom of lymphoma. Br J Urol. 1990 Dec. 66(6):658. [Medline].

  39. Gustafsson O, Norming U, Nyman CR, et al. Complications following combined transrectal aspiration and core biopsy of the prostate. Scand J Urol Nephrol. 1990. 24(4):249-51. [Medline].

  40. Kawahara M, Matsuhashi M, Tajima M, et al. Primary carcinoma of seminal vesicle. Diagnosis assisted by sonography. Urology. 1988 Sep. 32(3):269-72. [Medline].

  41. Stein AJ, Prioleau PG, Catalona WJ. Adenomatous polyps of the prostatic urethra: a cause of hematospermia. J Urol. 1980 Aug. 124(2):298-9. [Medline].

  42. Van Poppel H, Vereecken R, De Geeter P, et al. Hemospermia owing to utricular cyst: embryological summary and surgical review. J Urol. 1983 Mar. 129(3):608-9. [Medline].

  43. Walsh IK, Keane PF, Herron B. Benign urethral polyps. Br J Urol. 1993 Dec. 72(6):937-8. [Medline].

  44. Weidner W, Jantos C, Schumacher F, et al. Recurrent haemospermia--underlying urogenital anomalies and efficacy of imaging procedures. Br J Urol. 1991 Mar. 67(3):317-23. [Medline].

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