eMedicine Specialties > Urology > Erectile Dysfunction, Premature Ejaculation, and Sexual Disorders

Hematospermia: Differential Diagnoses & Workup

Author: Jonathan D Schiff, MD, Assistant Clinical Professor of Urology, Mount Sinai School of Medicine; Consulting Staff, Department of Urology, Mount Sinai Medical Center
Coauthor(s): John P Mulhall, MD, Director, Sexual Medicine Programs, Memorial Sloan-Kettering Cancer Center
Contributor Information and Disclosures

Updated: Nov 24, 2009

Differential Diagnoses

Abdominal Trauma, Blunt
Tuberculosis
Tuberculosis of the Genitourinary System

Other Problems to Be Considered

Prostate needle biopsy
Inflammatory conditions of the prostate or seminal vesicles
Hypertension
TB of the prostate, seminal vesicles, or vas deferens
Calculi of the prostate or seminal vesicles
Bleeding disorders
Prostate cancer
Malignancy of the seminal vesicles
Prostatic varices

Workup

Laboratory Studies

  • Urinalysis and culture
    • Urinalysis and culture may prove helpful because urogenital infections may be associated with hematospermia. Unfortunately, the rate of positive culture results is low, varying from 6-29%. Because this test is of low cost and a positive result suggests an etiology, urine culture is recommended in all patients who present with hematospermia.
    • If the history suggests exposure to TB, urine culture for acid-fast bacilli may prove helpful because TB is a cause of hematospermia in as many as 13% of patients in some series.
    • In younger men, urethritis should be considered in the differential diagnoses, and urethral swabs should be obtained and examined to help exclude nonspecific and gonococcal urethritis.
    • Blood in the urine mandates a more extensive evaluation of the genitourinary tract. At the authors' institution, patients presenting with hematuria undergo the following tests: urinalysis, urine culture, urine cytology, CT scan of the abdomen and pelvis with contrast, and cystoscopy.
  • Semen analysis and culture
    • The role of semen analysis and culture remains unclear. While advocated by some authors, the significance of a positive culture result remains uncertain because this may simply represent urethral contamination.
    • Semen analysis may prove helpful in the differentiation of true hematospermia from other causes of ejaculate discoloration.
    • Smith et al reported 2 cases of melanospermia as the presenting feature of malignant melanoma.15 Melanin produces a dark brown or black discoloration of semen rather than red or pink, which occurs with hematospermia. If necessary, the two can be differentiated based on chromatography findings. Normal semen should appear as a coagulum that liquifies over a 5- to 25-minute period.
    • Otherwise, laboratory analyses should be limited to an evaluation for bleeding disorders.
  • Blood work
    • Prostate-specific antigen analysis is recommended in all men older than 50 years, African American men, and men older than 40 years with a family history of prostate cancer. Hematospermia may be a harbinger of prostate cancer.
    • Coagulation studies are recommended in men of all ages with persistent hematospermia (>2 mo) because this condition is associated with coagulopathies.

Imaging Studies

  • Transrectal ultrasonography
    • The advent of TRUS has provided physicians with the single most important new tool for evaluating patients with hematospermia and has relegated the role of studies such as intravenous urography, vasography, and seminal vesiculography to that of only historical interest. TRUS and MRI allow clear visualization of the seminal vesicles, prostate, and ampullary portions of the vas. As a result, etiologic factors can now be identified more frequently.
    • Recently, 2 large series have evaluated the utility of TRUS in the investigation of patients with chronic hematospermia. In a study of 52 patients, Etherington et al found a significant number of patients with prostatic calculi and abnormalities of the seminal vesicles, including calculi, dilatation, cysts, abnormal lobulation, and asymmetry.8
    • More recently, Worischeck and Parra evaluated 26 patients with hematospermia using TRUS. They found abnormalities in 92% of patients, which included dilatated seminal vesicles (30%), ejaculatory duct cysts (15%), ejaculatory duct calculi (15%), seminal vesicle calculi (15%), and müllerian duct remnants (7%). No ultrasonographic evidence of malignancy was found in either series.16
    • The incidence of seminal vesicle abnormalities in these two series is similar to that in earlier studies that used biochemical assays and seminal vesiculography. Unfortunately, neither of these studies cited the mean patient age. This factor may have aided clinicians in stratifying patients in different treatment algorithms.
  • MRI
    • Maeda et al used MRI to study men with hematospermia and found abnormalities, including cyst formation or dilatation, in 14 of 15 patients.17
    • The best delineation of the seminal vesicles and their surrounding structures has been achieved with T2-weighted imaging.
    • MRI can help detect changes in anatomic structure secondary to endocrine therapy, radiation, inflammatory disorders, and neoplasia; however, the biggest advantage of MRI over TRUS is its ability to demonstrate hemorrhage within the seminal vesicles or prostate.
    • Endorectal MRI was recently found to be highly sensitive in terms of diagnosing abnormalities associated with hemospermia. Most of these abnormalities were benign.7
  • CT scan: Although CT scans have been used to study the morphology of the seminal vesicles, no studies have been published that specifically target men with hematospermia.
  • Cystourethroscopy: Given the association of hematospermia with urethral and prostatic lesions and in the absence of any urogenital infection or other discernible etiology, cystourethroscopy may aid the clinician in pinpointing the source of the bleeding. Of course, all patients with concomitant hematuria should undergo cystoscopy and an evaluation of the upper tract.

Procedures

  • Seminal vesicle endoscopy
    • Persistent hematospermia (>3 mo) without an antecedent cause or persistent hematospermia associated with an abnormality on ultrasonography or MRI may prompt further evaluation. Recently, a technique has been described whereby a 6F or 9F rigid ureteroscope is used to gain access to the prostatic utricle or ejaculatory ducts. In this manner, the scope is used to visually inspect the seminal vesicles, and a biopsy specimen may then be obtained from any abnormal area.
    • Seminal vesicle hemorrhage was found in 62% of patients, and calculi were found in 16%.

More on Hematospermia

Overview: Hematospermia
Differential Diagnoses & Workup: Hematospermia
Treatment & Medication: Hematospermia
Follow-up: Hematospermia
References
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Further Reading

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Keywords

hematospermia, hemospermia, bloody sperm, bloody ejaculate, bloody seminal fluid, bloody semen, blood in the ejaculate, prostate lesions, prostatitis, acute bacterial prostatitis, prostate cancer, prostate telangiectasia, prostate varices, prostatic telangiectasia, prostatic varices, prostatic calculi, transrectal biopsy, urethritis, urethral lesions, urethral cysts, urethral polyps, urethral condylomata, urethral strictures, urethral stricture disease, seminal vesicle cysts, genitourinary TB, genitourinary tuberculosis, schistosomiasis, urethral trauma, hemorrhoidal sclerosing injection, urethral self-instrumentation, testicular blunt trauma, perineal blunt trauma

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Contributor Information and Disclosures

Author

Jonathan D Schiff, MD, Assistant Clinical Professor of Urology, Mount Sinai School of Medicine; Consulting Staff, Department of Urology, Mount Sinai Medical Center
Jonathan D Schiff, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.

Coauthor(s)

John P Mulhall, MD, Director, Sexual Medicine Programs, Memorial Sloan-Kettering Cancer Center
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, and Society of University Urologists
Disclosure: Nothing to disclose.

Medical Editor

Edmund S Sabanegh Jr, MD, Director, Center for Male Fertility, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation
Edmund S Sabanegh Jr, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Society for the Study of Male Reproduction, Society of Reproductive Surgeons, and Southwest Oncology Group
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Gyrus-ACMI Honoraria Speaking and teaching

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, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
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