Haemospermia

Haemospermia is blood in the ejaculate. It is common, mostly benign, and usually self-limiting, and it accounts for about 1% of urological consultations. It is classified as primary (no cause found) or secondary, and as lasting or recurrent.

The underlying cause is not found in most men under 40 with a single episode.

Pathophysiology. Bleeding arises from the prostate, seminal vesicles, urethra, ejaculatory ducts or testes.

Causes:

• Infection and inflammation: prostatitis, urethritis, seminal vesiculitis, epididymitis, schistosomiasis and tuberculosis.
• Instrumentation and treatment: prostate biopsy (up to 30 to 50%, lasting up to 4 to 6 weeks), brachytherapy, radiotherapy, urethral surgery and vasectomy.
• Prostatic and seminal vesicle cysts, calculi and benign prostatic enlargement.
• Tumours: prostate, bladder, seminal vesicle and testicular cancer (found in about 3 to 5% of men over 40).
• Trauma, urethral vascular lesions, and perineal injury.
• Coagulopathy, anticoagulants, liver disease and uncontrolled hypertension.
• Hereditary haemorrhagic telangiectasia and other bleeding disorders.

Red, pink or brown semen. Check whether blood is also in the urine (haematuria). Associated features: pain, dysuria, frequency, penile discharge, fever, perineal pain, weight loss and bone pain. Ask about sexual contacts, travel to schistosomiasis endemic areas, recent biopsy, and anticoagulant use.

Examination: blood pressure, genitalia, epididymis and testes, digital rectal examination for prostate size, tenderness and nodules, and inguinal lymph nodes.

Concerning features: age over 40, recurrent or persisting episodes beyond 3 months, a prostate nodule, haematuria, weight loss, or a bleeding disorder.

• Urinalysis and culture. Nucleic acid testing for chlamydia and gonorrhoea in men under 40 and in those at risk.
• Blood pressure. Full blood count and coagulation screen when bleeding history or anticoagulation.
• PSA in men over 40, after counselling, at least 48 hours after ejaculation, and not during infection.
• Urine and semen microscopy for Schistosoma eggs in endemic exposure. Tuberculosis tests when suggested.
• Transrectal ultrasound or pelvic MRI for recurrent or persisting haemospermia (over 3 months), age over 40, or abnormal examination, to show cysts, calculi, ejaculatory duct dilation and prostate lesions.
• Cystoscopy when haematuria, or urethroscopy for urethral lesions.
• Prostate MRI and biopsy when PSA or examination suggests cancer.

Differential diagnosis.

• Haematuria
• Prostate cancer
• Prostatitis and seminal vesiculitis
• Seminal vesicle or prostatic cyst
• Urethral lesions (polyp, haemangioma)
• Genital infection
• Bladder or testicular tumour
• Bleeding disorder

• Men under 40 with a single episode, a normal examination and urine: reassurance and no treatment. It usually resolves within weeks, and a repeat episode needs review.
• Post-biopsy haemospermia: reassurance. It typically settles within 4 to 6 weeks, and rarely up to 12 weeks.
• Infection: culture directed antibiotic. Chlamydia and gonorrhoea: ceftriaxone 1 g intramuscularly once plus doxycycline 100 mg orally twice daily for 7 days. Acute bacterial prostatitis: ciprofloxacin 500 mg orally twice daily for 14 days, reduced when eGFR is under 50.
• Schistosomiasis: praziquantel 40 mg/kg orally on one day. Tuberculosis: a 6-month antituberculous regimen.
• Hypertension: control blood pressure. Anticoagulants: continue unless bleeding is troublesome, and review dose and indication with the prescriber.
• Persistent prostatic bleeding: finasteride 5 mg orally once daily for 3 to 6 months (limited evidence, with PSA halving and caution about handling by pregnant partners if tablets are crushed).
• Ejaculatory duct obstruction, cysts or calculi: transurethral resection of the ejaculatory ducts, endoscopic unroofing of the cyst, or lithotripsy.
• Cancer: treatment by tumour type and stage.
• Recurrent unexplained haemospermia in men over 40: ongoing surveillance, with PSA and imaging as indicated.

Special groups. Men over 40 and men with risk factors have a lower threshold for imaging and PSA. Men on anticoagulants need review of the dose and bleeding risk.

Monitoring. Review at 4 to 6 weeks for resolution. Repeat PSA at 3 to 6 months in men over 40, and repeat imaging if bleeding persists beyond 3 months.

Referral and escalation. Refer to urology for recurrent or persisting haemospermia, age over 40 with risk factors, raised PSA or abnormal examination, and haematuria. Urgent referral for suspected prostate cancer, heavy bleeding or retention.