Diagnosis

There are two main objectives for evaluation of haematospermia:

• to identify any underlying sinister cause or specific condition which can be treated
• if a causative factor is not identified to reassure the patient (1)

A systematic clinical history and physical examination is vital to recognize the cause of haematospermia.

• it is important to identify whether the patient is describing haematospermia or haematauria since both conditions may co exist in some patients (1).
• history –
  • age – although rare, malignancy should be considered in patients over the age of 40 years (2)
  • distinguish urethral bleeding from haematospermia;
  • note the amount, colour, duration and frequency of symptoms (3);
  • presence of any other urological symptoms – may indicate an urethral stricture or a vascular and enlarged prostate
  • trauma or any self instrumentation of the urogenital tract
  • a history of prolonged and intense masturbation or sexual intercourse may result in bleeding due to congestion of genital organs
  • family history of prostate cancer (3)
    
    
• examination –
  • abdomen – for hepatosplenomegaly, masses and palpable bladder
  • testes, epididymes, spermatic cord and the penile urethra – for any inflammatory and neo-plastic pathology.
  • urethral meatus – for evidence of trauma, condylomata, phimosis and cancer
  • rectum – for assessment of the prostate gland, tenderness or induration may indicate an infection while a hard texture or nodule may suggest neoplasia especially in an older individual
  • check blood pressure
    
    
• possible investigations include:
  • urine collection –
    • before and after prostatic massage and semen analysis
    • urinalysis and urine culture to exclude urinary infection and haematauria (1)
  • abdominal Xray – may reveal calcification in the prostate or urinary tract stones
  • transrectal ultrasonography (TRUS) – to diagnose prostatic and seminal vesicular pathology (1)
  • PSA and urine cytology in patients over 40 years
  • transrectal ultrasound scan
  • CT and MRI scans may be indicated in patients with doubtful lesions on ultrasound
  • cystourethroscopy
  • STI screen (3)
    
    
• Given there are so many possible investigations then a suggested initial assessment in primary care for haematospermia (4):
  
  
  • mid-stream urine sample for analysis and culture
    
    
  • consider other investigations guided by clinical findings:
    • investigations for a sexually transmitted infection (in men with symptoms or who are at risk)
    • full blood count, coagulation screen, and renal and liver function tests
    • prostate specific antigen (PSA) level if prostate cancer is suspected
    • scrotal ultrasound if there is testicular swelling.

Reference:

• (1) Kumar P, Kapoor S, Nargund V. Haematospermia - a systematic review. Ann R Coll Surg Engl. 2006;88(4):339-42
• (2) Magoha, G.A. and Magoha, O.B. Aetiology, diagnosis and management of haemospermia: a review. East African Medical Journal 2007;84(12), 589-594
• (3) Royal College of General Practitioners (RCGP) 2006. Sexually transmitted infections in primary care
• (4) CKS (Accessed 3/12/2013). Haematospermia