Haematospermia

Blood in the semen — often alarming to the patient, but usually benign. Distinguish true haematospermia from pseudo-haematospermia (blood from a partner, e.g. menstrual). Semen is contributed to by the epididymis, seminal vesicles, prostate, and Cowper/bulbourethral glands, so a lesion anywhere along that pathway can introduce blood.

Differential diagnosis

Most cases are idiopathic and benign, resolving spontaneously within days to months. The single most common known cause is recent prostate biopsy.

• Iatrogenic — prostate biopsy (the leading known cause); other instrumentation or trauma; prostate radiotherapy/brachytherapy; post-vasectomy; post-orchidectomy.
• Infection — prostatitis, urethritis, epididymitis, UTI, STI (chlamydia, gonorrhoea), viral (HIV, CMV, HSV); tuberculosis is uncommon. Schistosoma haematobium is a consideration only with relevant travel/residence history (Africa, Middle East, southeast Asia).
• Malignancy — prostate cancer (particularly age > 35–40), and occasionally tumours of the bladder, testes, urethra, or seminal vesicles.
• Benign prostatic hyperplasia.
• Trauma — coital or perineal; penile injections.
• Obstruction — ductal obstruction; cysts of the seminal vesicles/Wolffian duct/utricle; calculi of the seminal vesicles, ejaculatory duct, prostate, or urethra. Hemangiomas of the prostatic urethra or spermatic duct can cause massive haematospermia.
• Systemic disorders — bleeding disorders/anticoagulant use, chronic liver disease, lymphoma/leukaemia, amyloidosis.
• Idiopathic — the majority of cases.

If haematospermia and haematuria are both present, investigate as per haematuria.

Red flags

• Symptoms lasting > 1 month, without a recent prostate biopsy to explain them.
• Palpable lesion along the epididymis or on the prostate.
• Travel/residence history relevant to schistosomiasis.
• Systemic symptoms — fevers, weight loss, night sweats.
• Age > 40, recurrent/persistent episodes, or prostate cancer risk factors.

History

• Duration of symptoms, and association with sexual activity.
• Recent prostate biopsy or other instrumentation/trauma — ask specifically, as patients often don’t volunteer this.
• Associated symptoms: haematuria, obstructive voiding symptoms, nocturia, dysuria, penile discharge. Pain on ejaculation suggests prostatitis or (rarely) ejaculatory tract obstruction.
• Bleeding tendency — easy bruising, epistaxis, gum bleeding — and anticoagulant/ antiplatelet use.
• Constitutional symptoms suggesting infection or malignancy.
• Known prostate disease, pelvic radiotherapy, TB/HIV history or exposure, STI risk factors, family history of prostate cancer, and schistosomiasis exposure.
• Prolonged intercourse/masturbation, or conversely prolonged abstinence, can both be causes.

Examination

Inspect and palpate the external genitalia for inflammation, mass, or tenderness, particularly along the epididymis. DRE to assess the prostate for enlargement, tenderness, or a lump.

Investigations

Men under ~35–40 with a brief episode, normal history and examination, and no relevant travel history: usually no work-up is needed beyond urinalysis, urine culture, and STI testing.

Testing is indicated for: symptoms lasting > 1 month, haematuria, obstructive urinary symptoms, abnormal examination findings, or systemic symptoms — particularly in men over 40. Testing includes urinalysis, urine culture, PSA, and transrectal ultrasound; MRI and cystoscopy occasionally. Semen analysis is rarely needed but can help when travel history suggests possible schistosomiasis.

When to refer

Age > 40; persistent or recurrent episodes (> 1 month without a biopsy explanation); suspicious DRE findings; abnormal PSA; suspicion of prostate/ bladder/testicular/urethral malignancy; concurrent haematuria; or haematospermia persisting despite treating a suspected cause.

Management

Treatment targets the underlying cause where one is found. For the great majority of men, reassurance that haematospermia is not a sign of cancer and does not affect sexual function is the only intervention needed — post-biopsy haematospermia in particular is harmless, though it can persist for several weeks. If prostatitis is suspected clinically, an antibiotic course of 4–6 weeks is reasonable; avoid fluoroquinolones for uncomplicated presentations given the tendinopathy risk.