History

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.

Differential Diagnoses

Leocádio DE, Stein BS. Hematospermia: etiological and management considerations. International Urology and Nephrology. 06/19/2008. 41:77-83. [QxMD MEDLINE Link]. [Full Text].
Aslam MI, Cheetham P, Miller MA. A management algorithm for hematospermia. Nat Rev Urol. 2009 Jul. 6(7):398-402. [QxMD MEDLINE Link].
Fletcher MS, Herzberg Z, Pryor JP. The aetiology and investigation of haemospermia. Br J Urol. 1981 Dec. 53(6):669-71. [QxMD MEDLINE Link].
Leary FJ, Aguilo JJ. Clinical significance of hematospermia. Mayo Clin Proc. 1974 Nov. 49(11):815-7. [QxMD MEDLINE Link].
Ahmad I, Krishna NS. Hemospermia. J Urol. 2007 May. 177(5):1613-8. [QxMD MEDLINE Link].
Ganabathi K, Chadwick D, Feneley RC, et al. Haemospermia. Br J Urol. 1992 Mar. 69(3):225-30. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Madhushankha M, Jayarajah U, Abeygunasekera AM. Clinical characteristics, etiology, management and outcome of hematospermia: a systematic review. Am J Clin Exp Urol. 2021. 9 (1):1-17. [QxMD MEDLINE Link]. [Full Text].
Prando A. Endorectal magnetic resonance imaging in persistent hemospermia. Int Braz J Urol. 2008 Mar-Apr. 34(2):171-7; discussion 177-9. [QxMD MEDLINE Link].
Efesoy O, Çayan S, Aşcı R, Orhan İ, Yaman Ö. Hematospermia is rarely related to genitourinary cancer: lessons learned from 15 years of experience with 342 cases. Int J Impot Res. 2021 Sep. 33 (6):627-633. [QxMD MEDLINE Link].
Ng YH, Seeley JP, Smith G. Haematospermia as a presenting symptom: outcomes of investigation in 300 men. Surgeon. 2013 Feb. 11(1):35-8. [QxMD MEDLINE Link].
Hakam N, Lui J, Shaw NM, Nabavizadeh B, Smith JF, Eisenberg ML, et al. Hematospermia is rarely associated with urologic malignancy: Analysis of United States claims data. Andrology. 2022 Apr 28. [QxMD MEDLINE Link].
Etherington RJ, Clements R, Griffiths GJ, et al. Transrectal ultrasound in the investigation of haemospermia. Clin Radiol. 1990 Mar. 41(3):175-7. [QxMD MEDLINE Link].
Furuya S, Kato H. A clinical entity of cystic dilatation of the utricle associated with hemospermia. J Urol. 2005 Sep. 174(3):1039-42. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Finney G, Haynes AM, Cross P, et al. Cross-sectional analysis of sexual function after prostate brachytherapy. Urology. 2005 Aug. 66(2):377-81. [QxMD MEDLINE Link].
Walsh IK, Keane PF, Herron B. Benign urethral polyps. Br J Urol. 1993 Dec. 72(6):937-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Koment RW, Poor PM. Infection by human cytomegalovirus associated with chronic hematospermia. Urology. 1983 Dec. 22(6):617-21. [QxMD MEDLINE Link].
Yu HH, Wong KK, Lim TK, et al. Clinical study of hemospermia. Urology. 1977 Dec. 10(6):562-3. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Downs JA, de Dood CJ, Dee HE, McGeehan M, Khan H, Marenga A, et al. Schistosomiasis and Human Immunodeficiency Virus in Men in Tanzania. Am J Trop Med Hyg. 2017 Apr. 96 (4):856-862. [QxMD MEDLINE Link].
Whyman MR, Morris DL. Retrovesical hydatid causing haemospermia. Br J Urol. 1991 Jul. 68(1):100-1. [QxMD MEDLINE Link].
Radfar MH, Simforoosh N, Sotoudeh M, Ramezani MH, Mollakoochakian MJ, Nikravesh M, et al. What is the impact of extracorporeal shock wave lithotripsy on semen parameters? A systematic review and meta-analysis. Urologia. 2017 Feb 3. 84 (1):28-34. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Close CF, Yeo WW, Ramsay LE. The association between haemospermia and severe hypertension. Postgrad Med J. 1991 Feb. 67(784):157-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Manoharan M, Ayyathurai R, Nieder AM, Soloway MS. Hemospermia following transrectal ultrasound-guided prostate biopsy: a prospective study. Prostate Cancer and Prostatic Diseases. 2/20/2007. 10:283-287. [QxMD MEDLINE Link]. [Full Text].
Liao LG, Li YF, Zhang Y, Li K, Zhu T, Li BJ, et al. Etiology of 305 cases of refractory hematospermia and therapeutic options by emerging endoscopic technology. Sci Rep. 2019 Mar 22. 9 (1):5018. [QxMD MEDLINE Link]. [Full Text].
Khodamoradi K, Kuchakulla M, Narasimman M, Khosravizadeh Z, Ali A, Brackett N, et al. Laboratory and clinical management of leukocytospermia and hematospermia: a review. Ther Adv Reprod Health. 2020 Jan-Dec. 14:2633494120922511. [QxMD MEDLINE Link]. [Full Text].
Ambakederemo TE, Dodiyi-Manuel ST, Ebuenyi ID. Bloody semen, severe hypertension and a worried man. Pan Afr Med J. 2015. 20:326. [QxMD MEDLINE Link].
[Guideline] Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ, et al. Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol. 2012 Dec. 188 (6 Suppl):2473-81. [QxMD MEDLINE Link]. [Full Text].
Smith GW, Griffith DP, Pranke DW. Melanospermia: an unusual presentation of malignant melanoma. J Urol. 1973 Sep. 110(3):314-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Worischeck JH, Parra RO. Chronic hematospermia: assessment by transrectal ultrasound. Urology. 1994 Apr. 43(4):515-20. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Maeda H, Toyooka N, Kinukawa T, et al. Magnetic resonance images of hematospermia. Urology. 1993 May. 41(5):499-504. [QxMD MEDLINE Link].
Yang SC, Rha KH, Byon SK, et al. Transutricular seminal vesiculoscopy. J Endourol. 2002 Aug. 16(6):343-5. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Alexander D Tapper, MD Resident Physician, Department of Urology, William Beaumont Hospital

Alexander D Tapper, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Urological Association, Michigan State Medical Society

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 Urology, Department 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 Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Antares.

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.

John P Mulhall, MD Director, Sexual and Reproductive Medicine Program, 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, Society of University Urologists

Disclosure: Nothing to disclose.

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.

Hematospermia Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

What would you like to print?