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

Hematospermia

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 25, 2008

Introduction

Background

Hematospermia is defined as blood in the semen. While often perceived as a symptom of little significance, blood in the ejaculate can cause great concern to the men who experience it. The condition is common, and many episodes go unnoticed; therefore, the prevalence of hematospermia remains unknown. In most patients with hematospermia, no further diagnostic workup is needed; however, in some patients, hematospermia may be the first indicator of other urologic diseases.

Hematospermia has been written about for centuries. Hippocrates, Galen, Pare, Morgagni, and Fournier all commented on this condition. The first American report appeared in 1894, and Fletcher,¹ Leary,² Marshall,³ and Ganabathi⁴ have subsequently published excellent contemporary reviews on the subject. The advent of newer imaging modalities has altered both the diagnosis and the treatment of hematospermia.

Pathophysiology

For an understanding of the causes of hematospermia, a working knowledge of the relevant anatomy of the ejaculatory complex is useful.

The seminal vesicles are androgen-dependent accessory organs that produce and store seminal fluid, which is essential to male fertility. The seminal vesicles are best studied ultrasonographically. Normal seminal vesicles are flat paired structures that lie cephalad to the prostate behind the bladder and have a bow-tie appearance on transverse imaging. They are symmetric, well-defined, saccular, elongated organs. In its normal collapsed state, the center of the gland is homogenous, with areas of increased echogenicity corresponding to the folds of secretory epithelium. In the distended state, the wall is visibly composed of 2 distinct layers. Caudally, the seminal vesicles diverge laterally.

The dimensions of the seminal vesicles vary with age, but not with the ejaculatory state. Upon transrectal ultrasonography (TRUS), the dimensions are estimated to be 30 ± 5 mm in length, 15 ± 4 mm in width, and 13.7 ± 3.7 mL in mean volume. The age of the patient and degree of prostate enlargement have been shown to cause variation in the size of the seminal vesicles.

MRI findings may also help delineate the normal anatomy of the seminal vesicles. Using MRI, the signal intensity of the seminal vesicles can be compared with the tissues surrounding them (ie, skeletal muscle, fat, urine). The signal intensity on T1-weighted spin-echo images of normal seminal vesicles in men is similar to or slightly higher than that of skeletal muscles and is always greater than that of urine. On T2-weighted images, the signal intensity varies. In prepubertal boys and men older than 70 years (androgen-deprived males), the signal intensity is generally lower than that of skeletal muscle or urine. Convolutions of the seminal vesicles are best observed on T2-weighted images or on T1-weighted images with the use of intravenous contrast agents.

The vasa deferentia act as conduits, carrying sperm between the epididymis and the ejaculatory ducts via the vasal ampullae. The vasal ampullae pass medially to the seminal vesicles and are best seen using transaxial TRUS views.

The seminal vesicles and vasal ampullae join together to form the ejaculatory duct. The ejaculatory duct travels through the prostate and enters the urethra at the level of the verumontanum. The junction between the seminal vesicle and the ejaculatory duct lies within the prostate and is difficult to see in a healthy unobstructed system. Small echodensities are frequently seen at the junction of the ejaculatory ducts and the verumontanum in the urethra. These areas provide useful landmarks and are thought to represent concretions within the periurethral glands surrounding the verumontanum.

Frequency

United States

The true prevalence of hematospermia is unknown because most ejaculations occur intravaginally and hematospermia often remains unrecognized.

Sex

Hematospermia affects only males.

Age

Hematospermia can occur in males of any age. In younger men (<40 y), hematospermia is uniformly benign. Even in older men, it is rarely associated with malignancy.

Clinical

History

• A good patient history that concentrates on trauma, infection, and bleeding disorders often helps to narrow the differential diagnoses associated with hematospermia.
• Most men with hematospermia are young (mean age, <40 y) and have symptoms ranging in duration from 1-24 months.
• 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.

Physical

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).

• 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.

Causes

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 6 patients eventually developed prostate carcinoma, and none had prostate carcinoma diagnosed at the time of the initial evaluation.
  • However, a recent 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.⁶ This is still a controversial area of investigation. More recently, Prando (2008) reported on a series of 86 men with hemospermia and found prostate cancer in only one patient.⁷
  • 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 experiencing 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.⁸
  • Another (2005) 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.⁹
  • 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. In 2004, 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.⁵
    • 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.¹⁰
    • 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.¹¹
• 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.¹² 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; 4 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.⁷
• Infections
  • 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.¹³
  • A recent 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 5, Chlamydia trachomatis in 4, Enterococcus faecalis in 2, and Ureaplasma urealyticum in one. Culture-specific antibiotics were administered, and hematospermia resolved in all the patients.¹⁴
  • Several authors have reported schistosomiasis 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
  • 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 (von Willebrand disease). 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 severe uncontrolled hypertension, elevated serum creatinine levels, severe proteinuria, and renovascular disease.

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