Hematospermia
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Background
Hematospermia is defined as blood in the semen. This is, in fact, a fairly common condition. Fortunately, it is rare for there to be a serious cause. Hematospermia is very different than hematuria, or blood in the urine, as visible hematuria is frequently associated with serious causes such as bladder cancer. As a result, it is very important to differentiate hematospermia from hematuria. Fresh bleeding usually appears as bright red whereas old blood can produce a brownish or chocolate-colored ejaculate. Sometimes the bleeding may be profuse and quite alarming.
Causes
In order for blood to appear in the ejaculate, the bleeding must originate at some point along the reproductive tract which stretches from the testes through to the tip of the penis. The potential sites from which the bleeding originate can include (in order from the testis) the epididymis, vas deferens, seminal vesicles, prostatic urethra and the penile urethra. There is a very long list of conditions which can affect of these structures or predispose to bleeding (e.g. blood thinners). The most common things include benign prostatic enlargement, infections and idiopathic rupture of blood vessels in the seminal vesicles. Any Internet search of hematospermia will usually produce an incredibly long list of conditions, some serious such as cancer and some very rare such as tuberculosis, which could cause hematospermia. In reality, these causes are very rare and the most common final diagnosis by far is idiopathic (we cannot find a cause). We are not so much interested in localizing the bleeding (which is not possible and probably futile in many cases) but interested in excluding serious causes in men who are at risk. Fortunately, hematospermia is a presenting sign of serious disease and probably less than 1-in-100 men who have hematospermia.
Diagnosis & Evaluation
The diagnostic approach to hematospermia is to exclude serious causes in men who are at risk of harboring the serious causes since the cause will be benign in the vast majority of men. As always, a complete evaluation starts with an interview and physical examination. It is rarely possible to localize the site of the bleeding, but it is fairly easy to exclude the short list of serious causes with routine testing such as cystoscopy, urine testing and occasional use of imaging (most frequently ultrasound). Men who were most at risk for serious causes are those who have risk factors for prostate cancer such as age or an abnormality on prostate exam as well as smokers.Smoking predisposes to cancers of the lining of urinary tract and therefore need to be evaluated more extensively.
In most men, a history, physical examination and some simple lab tests are sufficient
Urine analysis to exclude hematuria
Urine cultures to exclude infection; specific testing for STI as indicated
PSA in older males
Treatment
If a specific cause is found, then this can be addressed with specific treatment. In most men the cause is idiopathic (i.e. a specific cause is not identified) and therefore the treatment of hematospermia is conservative in most men. Sometimes, 5 alpha reductase inhibitors such as Avodart (dutasteride) or Proscar (finasteride) are used. The rationale for using these medications is that benign prostatic growth (BPH/BPE) can be associated with the development of increased blood flow to the prostate and of the growth of fragile blood vessels within the prostatic urethra. These blood vessels can be prone to bleeding, especially with the increased pressures associated with ejaculation. Shrinking the prostate down can reduce the chances of bleeding. This is an off-label use for these medication. There can be side effects associated with usage and therefore discussion with your urologist is recommended.
On the Web
emedicine info on hematospermia
General Urology Websites
Canadian Urological Association Extensive library of downloadable pamphlets on a wide range of urological conditions
Medline Plus Produced by the US National Institutes of Health with information on virtually every health topic and extensive list of links
UrologyHealth.org The patient information site of the American Urological Association.