Hematospermia Clinical Presentation
- Author: Jonathan D Schiff, MD; Chief Editor: Edward David Kim, MD, FACS more...
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.
The physical examination should include measuring the patient's blood pressure, because severe hypertension is associated with hematospermia. 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.
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. 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.
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.
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.
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.
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.
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.
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.
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. 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.
Infections and inflammatory disorders account for 40% of cases. Infectious causes of hematospermia include tuberculosis (TB), HIV infection, and cytomegalovirus infection. Yu and colleagues found that 11% of a cohort of 65 patients with genitourinary TB had hematospermia during their disease.
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.
Genitourinary schistosomiasis has been reported as a cause of hematospermia. 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.
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 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
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.
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