Approach Considerations
In younger men with nonpersistent hematospermia, only a digital rectal examination (DRE), along with a check of vital signs, is required as part of a careful physical examination. In older men (>50 y) with nonpersistent hematospermia without concomitant hematuria upon urinalysis, a basic evaluation consists of a DRE and a prostate-specific antigen measurement. Persistent hematospermia (>2 months without defined etiology) warrants further workup, as described below.
Laboratory Studies
Urinalysis and culture
Urinalysis and culture may prove helpful because urogenital infections may be associated with hematospermia; 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.
In younger men, urethritis should be considered in the differential diagnoses. Testing should be performed to help exclude nonspecific and gonococcal urethritis.
If the history suggests exposure to tuberculosis (TB), urine culture for acid-fast bacilli may prove helpful because TB can be a cause, though rare, of hematospermia.
Blood in the urine mandates a more extensive evaluation of the genitourinary tract. The workup should proceed according to American Urological Association guidelines [35] and can include any of the following, depending on the patient's age, risk factors, and whether the hematuria is asymptomatic or symptomatic as well as microscopic vs gross.
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Urinalysis
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Urine culture
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Urine cytology
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Computed tomography (CT) urogram (alternative options are available for patients with contrast allergies or kidney function that prohibits use of iodinated contrast intravenously)
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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 two cases of melanospermia as the presenting feature of malignant melanoma. [36] If necessary, the two can be differentiated based on chromatography findings.
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 months) because this condition is associated with coagulopathies.
Otherwise, laboratory analyses should be limited to an evaluation for bleeding disorders if clinically warranted.
Transrectal Ultrasonography
The advent of transrectal ultrasonography (TRUS) has provided physicians with an important 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. [37] 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.
TRUS is not recommended for routine use in patients initially presenting with hematospermia. [11] However, TRUS can be valuable for evaluating older patients or those with persistent hemospermia or associated symptoms. [5]
Three 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 that 83% of these patients had abnormalities on imaging such as prostatic calculi, or abnormalities of the seminal vesicles (eg, calculi, dilatation, cysts, abnormal lobulation, asymmetry). [13]
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. [38]
In a study by Raviv et al of 115 consecutive patients with hematospermia who were evaluated with TRUS, all the patients were found to have an abnormality, almost all of them benign. Abnormalities included hypoechogenicity within the peripheral zone of the prostate, prostatic calculi, cysts within the seminal vesicles, and/or dilation of the seminal vesicles or ejaculatory ducts. In 10 patients a 12-core TRUS-guided biopsy of the prostate was taken; none of the samples were positive for tumor. [39]
Magnetic Resonance Imaging
Maeda et al used MRI to study men with hematospermia and found abnormalities, including cyst formation or dilatation, in 14 of 15 patients. In 11 of 15 patients there was abnormal signal intensity of the seminal vesicles though to be secondary to subacute hemorrhage. [40]
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.
A 2008 study by Prando evaluated the utility of endorectal MRI in patients with chronic hematospermia and found it to be highly sensitive in terms of diagnosing abnormalities associated with hematospermia. Most of these abnormalities were benign. [9]
Seminal Vessel Endoscopy
Persistent hematospermia (>3 mo) without an antecedent cause or persistent hematospermia associated with an abnormality on ultrasonography or MRI may prompt further evaluation. Yang et al described a technique in which 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. In a study of this procedure by Yang et al, seminal vesicle hemorrhage was found in 62% of patients, and calculi were found in 16%. [41] A study by Xing et al, found that transurethral seminal vesiculoscopy was superior to transrectal ultrasonography for detecting calculi and obstruction/stricture in men with persistent hematospermia. [37]
Imaging Studies
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 urinary tract.
