Management of Hematospermia in the Family Practice Setting Reviewed

Laurie Barclay, MD

December 28, 2009

December 28, 2009 — Recommendations for evaluation and treatment of hematospermia in the family practice setting are reviewed in an article published in the December 15 issue of American Family Physician.

"Presence of blood in the semen, known as hematospermia or hemospermia, is often a frightening finding for patients," write Ksenija B. Stefanovic, MD, PhD, from Virginia Mason Medical Center in Seattle, Washington, and colleagues. "Most cases of hematospermia can be appropriately managed by primary care physicians. Hematospermia is commonly benign and self-limited, especially in men younger than 40 years without risk factors and in men with no associated symptoms."

Although hematospermia is usually benign, a thorough history, physical examination, and laboratory testing are needed to rule out significant underlying pathologic disease. Other diagnostic modalities may also be indicated in select cases. Risk factors for serious underlying causes of hematospermia include history of cancer, known urogenital malformation, and bleeding disorders.

Infection is the most common cause of hematospermia, accounting for nearly 40% of cases. Behavioral causes, such as excessive or interrupted sex, or prolonged sexual abstinence, are also common, as is iatrogenic trauma from prostate biopsy or other urogenital procedure. Additional causes may include inflammatory conditions; cancer; structural anomalies; vascular causes; or systemic conditions such as amyloidosis, bleeding disorders, chronic liver disease, or hypertension.

"The first step of the history is to rule out pseudo-hematospermia by determining if hematuria is being misinterpreted as hematospermia or if the blood may have been from the patient's sexual partner (e.g., ask about his partner's possible menstruation or genitourinary infection, and about intense sexual behavior)," the study authors write. "Once true hematospermia has been confirmed, three key factors help guide further evaluation: age of the patient, duration of symptoms, and presence of associated symptoms or risk factors."

In men younger than 40 years who have no risk factors and in men with no associated symptoms, hematospermia is often self-limited, needing no additional assessment or treatment beyond reassuring the patient. Men in this age group who have lower urinary tract symptoms in addition to hematospermia often have sexually transmitted infections or other urogenital infections. In these patients, urinalysis and testing for sexually transmitted infections, with treatment as indicated, typically suffices for appropriate management.

Iatrogenic hematospermia caused by urogenital instrumentation or prostate biopsy is the most common cause of blood in the semen in men 40 years and older. Recurrent or persistent hematospermia, or associated symptoms such as fever, chills, weight loss, and/or bone pain, mandates additional assessment. This should begin with a prostate examination and prostate-specific antigen testing to determine if prostate cancer is present. In this age group, other possible causes of hematospermia include genitourinary tract infections, inflammations, vascular malformations, stones, tumors, and systemic disorders causing increased bleeding.

Examination findings of significance in the evaluation of hematospermia include scrotal inflammation or infection; masses of the testes, epididymis, and spermatic cords; and abnormal rectal examination findings regarding prostate size, tenderness, fluctuation, symmetry, firmness, and nodularity.

When genitourinary tract infection is suspected, a 2-week course of fluoroquinolones, doxycycline, trimethoprim, or trimethoprim/sulfamethoxazole may be appropriate, as each of these antibiotics penetrates the prostate-blood barrier.

Clinical Recommendations

Specific key clinical recommendations for practice, all rated level of evidence, C, are as follows:

  • Men younger than 40 years who have limited episodes of hematospermia and no risk factors or associated symptoms can be assessed for common genitourinary tract diseases, given appropriate therapy as indicated, and reassured.

  • For those men with hematospermia who are 40 years or older, who have associated symptoms, or who have persistent hematospermia, assessment should be more comprehensive and should include evaluation for underlying prostate cancer.

  • For low-volume hematospermia of iatrogenic cause, observation is typically the most appropriate management strategy because these cases of hematospermia are often self-limiting.

Indications for Urology Referral

Indications for referral to a urologist in patients with hematospermia include associated symptoms of genitourinary pain or unexplained voiding symptoms, or recurrent, persistent, high-volume hematospermia. Abnormal evaluation findings should also prompt urology referral, including examination suggestive of tumor or structural problems, abnormal prostate-specific antigen findings, and abnormal urinalysis findings such as hematuria or sterile pyuria.

Other conditions in which urology consultation is indicated include suspected foreign body, stent migration, suspected vascular malformation, and persistent symptoms or abnormal findings.

"Most men with an easily treatable cause of hematospermia do not need follow-up," the review authors conclude. "Men with recurrent or persistent isolated hematospermia or symptomatic men in whom an etiology is not elucidated require follow-up within three to six months to reassess symptoms and potential etiologic factors. Poor response to treatment or troublesome associated symptoms or findings should prompt referral to a urologist."

The review authors have disclosed no relevant financial relationships.

Am Fam Physician. 2009;80:1421-1427. Abstract