Introduction
Haematospermia is the presence of blood in the semen. Whilst often an alarming symptom for patients, it is usually benign and self-limiting.
It can be a result of pathology to the prostate, testes, epididymis, vas deferens, seminal vesicles, ejaculatory ducts, urethra, or bladder.
Aetiology
Haematospermia can commonly be as a result of recent urological procedure, such as a prostate biopsy (most common cause*), radiotherapy, vasectomy, or cystoscopy.
Infections are another common cause and may be of the urinary tract (UTI) or a result of sexually transmitted infections (STIs), such as gonorrhoea or chlamydia. Rarely, it may be secondary to schistosomiasis or tuberculosis.
Other, less frequent causes include local trauma, benign prostatic conditions (prostatitis, or benign prostatic hyperplasia), malignancy of the prostate, kidney, or bladder, or underlying vascular abnormalities or clotting disorders.
*Haematospermia may be experienced by up to 80% of patients who undergo a prostate biopsy – it will usually resolve within 3-4 weeks
Figure 1 – A case of haematospermia
Clinical Features
Assessment should include a thorough history and examination. Important features of the history should include asking about any recent urological procedures or trauma, and the presence of any urinary tract symptoms.
Ensure to clarify the frequency and duration of symptoms, along with the presence of any haematuria. Features which may be associated with a serious underlying cause are chronicity >1 month or patient age ≥40 years.
Examination of the abdomen, scrotum, lymph nodes, and a digital rectal examination should be performed.
Investigations
Initial investigations may include a urine dipstick +/- urine culture to investigate for underlying infection. An appropriate STI screen should be performed if an STI is suspected*. Routine blood tests such as a Full Blood Count, Clotting Screen, or a PSA test may be considered depending on patient risk profile.
Relevant imaging studies will be guided by the clinical features, however may include Trans-Rectal Ultrasound (TRUS) to assess the prostate, scrotal ultrasound if any scrotal masses or discomfort is elicited on examination, or cystoscopy for direct visualisation of the lower urinary tract.
*Sperm testing is not routinely required, however can be considered for analysis if an underlying cause of schistosomiasis or tuberculosis is suspected.
Management
In most cases, reassurance may be offered*, particularly if haematospermia has occurred as an isolated episode, in younger patients who are otherwise asymptomatic, and last for a short period only. For patients who have had a recent urological procedure, such as prostate biopsy, may be reassured that the haematospermia should resolve within a few weeks.
Infective causes, such as UTI or STI, should be treated with appropriate antibiotic therapy. Contact tracing should be considered if STI is found to be the cause.
Current guidance advises urgent referral to a urologist for further assessment if the history, examination, or investigations are suggestive of underlying prostatic, urinary tract, or testicular malignancy. Additionally, patients with persistent haematospermia without an identifiable cause, unresponsive to treatment, or those aged ≥40yrs may be considered for referral.
*Haematospermia is unlikely to affect fertility, especially if an underlying STI has been ruled-out
Key Points
- Haematospermia refers to the presence of blood in semen
- It is usually benign and self-limiting
- Most common causes include recent urological procedure or infection
- A referral to urology services should be considered if there if is persistence of the Haematospermia or if there are features concerning for a urological malignancy
