diagnosis

Last reviewed 01/2018

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.

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