Approach Considerations
The primary goal in the management of hematospermia is to properly counsel patients who have a condition that can be extremely anxiety-provoking but is often self-limited and benign. Hematospermia is rarely associated with significant pathology, especially in younger men. The three factors that dictate the extent of the evaluation and treatment include the following:
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The patient's age – Most malignancies associated with hematospermia occur in patients older than 40 years.
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The duration and recurrence of the hematospermia – Chronic hematospermia warrants more aggressive intervention to identify an etiologic factor.
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The presence of associated hematuria
Urogenital infections require appropriate antibiotic therapy, which normally resolves the problem. In all men, enterobacteria (especially Escherichia coli) should be covered if empiric therapy is used. In younger men, concomitant therapy for chlamydial infections should also be used if an infectious etiology is pursued. A fluoroquinolone should adequately treat both organisms. If the patient is allergic to fluoroquinolones or cannot afford this class of drugs, a combination of trimethoprim/sulfamethoxazole and doxycycline is often successful. A 2-week course is usually sufficient. Concomitant inflammation may be treated with ibuprofen or other nonsteroidal anti-inflammatory drugs.
Urethral or prostatic varices are best fulgurated. Cysts, of either the seminal vesicles or prostatic urethra, can be aspirated transrectally.
For calculi in the ejaculatory ducts or seminal vesicles, Oh and Seo reported successful resolution of hematospermia in 13 of 15 patients with endoscopic treatment and a holmium laser. After dilation with a guidewire and ureteral serial dilator and introduction of a semi-rigid ureteroscope, a holmium laser was used to incise the obstructed ejaculatory duct, coagulate hemorrhagic mucosa, and fragment the calculi in the ejaculatory duct or seminal vesicles. Stones were removed using a basket and forceps. [42]
Liao et al reported successful treatment of refractory hematospermia and ejaculatory duct obstruction with transurethral endoscopy or seminal vesiculoscopy. The specific endoscopic procedures used varied with the etiology of the obstruction and included fenestration in the prostatic utricle, irrigation, lithotripsy, stone removal, electroexcision, fulguration, and transurethral resection/incision of the ejaculatory duct. [32]
Currently, no evidence suggests that the injection of any substance, coagulant or sclerosant, has any role in the management of hematospermia. Fuse and colleagues injected coagulant substances into dilated seminal vesicles under transrectal ultrasound guidance in seven patients with hematospermia, there was temporary resolution however, the hematospermia returned several months later. [43]
Bleeding diatheses or other systemic disorders should be managed in the appropriate manner.
In men with coexisting bladder outlet obstruction, a 5-alpha reductase inhibitor may be used.
No rationale currently exists for the use of oral agents, such as estrogens or corticotropins, which have been used in the past.
Surgical Care
Patients in whom bleeding prostatic variceal veins are suggested as the cause of hematospermia are candidates for fulguration. After infectious causes have been excluded in cases of persistent hematospermia, cystourethroscopy is performed. If large friable prostatic veins are discovered and examination findings are otherwise normal, fulguration with a Bugbee or loop electrode can be performed. Prior to fulguration, a biopsy should be performed on any suggestive lesions.
More recently, a technique of endoscopy of the ejaculatory ducts and seminal vesicles has been described. [37, 44, 45] This technique involves using a semirigid ureteroscope to cannulate the ejaculatory duct and allows the surgeon to examine the duct, seminal vesicle, and ampulla of the vas. However, the author reserves this technique for only the most refractory cases of hematospermia that involve significant physiologic comorbidity (eg, urinary retention or persistent hematuria) or psychological trauma (avoidance of ejaculation).
Long-Term Monitoring
In the absence of recurrence, no specific follow-up for hematospermia is warranted. Chronic (>2 mo) or recurrent hematospermia should be evaluated on the basis of the associated clinical features.
