Hematospermia Clinical Presentation

Updated: May 19, 2022
  • Author: Alexander D Tapper, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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When hematospermia is visible macroscopically, the color of the ejaculate may vary depending on how much time has passed since hemorrhage took place. If fresh blood is present, the semen may range in color from light red to brownish; with old bleeding, the semen may be dark brown or contain black clots. [32]

In addition to confirming that the blood is not in the patient’s urine or from his sexual partner, questions about the following can often help to narrow the differential diagnoses associated with hematospermia:

  • Pain (eg, on erection, penetration, or ejaculation; or in the genital or perineal area)
  • Signs and symptoms of urinary tract infection (eg, urinary frequency, dysuria)
  • Previous pelvic procedures (eg, prostate biopsy) [33] or trauma
  • Bleeding disorders

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. [5]


Physical Examination

The physical examination should include measuring the patient's blood pressure, because severe hypertension is associated with hematospermia. [34]  This association is well recognized; however, the exact mechanism by which it occurs is unclear. The basis may be similar to that of the association between hypertension and epistaxis (nosebleeds).

Careful attention should be paid to the following during physical examination; the penis and urethral meatus should be carefully inspected to rule out any lesions that may bleed and contribute to the ejaculate.

The vasa should be palpated and followed along their 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 may rarely be a harbinger of prostate cancer.