Haemospermia or Hematospermia
Hematospermia or haemospermia is a very disturbing symptom among men, but can be managed in many cases without further complications.
Because it is not a habitual demand in consultation, it requires epidemiological knowledge and an adequate clinical judgment in order to be able to approach each case correctly and reassure our patients.
Hematospermia or haemospermia is defined as the presence of blood in the semen or sperm. The most frequent cases are in men between 30 and 40 years old.
It is recurrent: when it persists for more than a month or is present in more than 10 ejaculations.
When semen is stained bright red, it means that the bleeding is recent (within the last 48 hours).
When the cause of the bleeding is several days or weeks ago, the color is rusty brown or with brown lumps inside the semen.
It can even be invisible to the naked eye, in which case we speak of microhemospermia.
The medical history is the most important part of our intervention, because by answering 3 questions such as age, duration of bleeding and the appearance of symptoms or associated risk factors, we can guide the case.
It is in the diagnosis where most progress has been made in recent years, getting to know the cause of hematospermia in most cases.
This is generally a middle-aged male who goes to the primary care emergency department because in his last ejaculation a few minutes ago he observed the presence of blood along with the rest of the semen.
The patient comes very concerned about this circumstance, in the general examination there is no data or sign of interest, in testicular palpation, there may be painful epididymal thickening or not.
A urine strip test is performed, all parameters may be be normal.
In the laboratory tests nothing of note appears. Depending on the evolution and the tests obtained, the patient is diagnosed with self-limited hematospermia without filiar (negative cultures), of possible epididymary inflammatory origin resolved after antibiotic coverage.
The presence of blood in the ejaculate causes anguish, fear and urgent consultations, being in 75% of the occasions of self-limited character (less than one month) and isolated (it does not repeat itself).
However, there may be general symptoms such as:
Bone or joint pain
Abnormal discharge from the penis
Signs of sexually transmitted infections
Swollen sex organs
Itching when urinating
Even so, the exact incidence is not well known, because ejaculations often go unnoticed during intercourse.
Unlike in the past, today, thanks to new imaging techniques, the origin of the bleeding is discovered up to 85% of the time.
A typical case is that in transrectal and scrotal prostatic ultrasound only a small cystic image of superficial location in a testicle and moderate ipsolateral hydrocele (compatible with epididymitis) can be highlighted. Approximately 20 days after the onset, hematospermia ceases.
Age is a fundamental factor when assessing the origin and prognosis of hematospermia.
In order to do this, two groups are established, those under and those over 40 years of age, with a higher incidence being observed in the first group. In men under 40 years of age, it is usually a painless, self-limited and benign sign.
The origin is mainly infectious-inflammatory (prostatitis, vesiculitis, epididymitis) and the neoplasms are exceptional.
Over the age of 40, iatrogenic lesions, also self-limited and benign, are the most frequent as a result of the diagnostic and therapeutic development of prostate cancer.
Especially the transrectal prostate biopsy that can produce hematospermia in 45% of those subjected to this technique.
Cancer as the main cause appears on average in this group in 3.5% of cases, according to the reviews consulted (14% in a study published as the highest figure).
Especially the prostate, although not hematospermia, the most common form of presentation.
In this age group, non-specific prostate lesions (hyperplasia, calcification, cysts) and prostatitis as a cause of bleeding in the seminal fluid are also frequently found.
It has sometimes been associated with systemic diseases such as uncontrolled hypertension, coagulopathies, liver disease, amyloidosis and lymphoma.
-Origin of hematospermia:
-Causes of hematospermia in males under 40 years of age
Inflammatory – Infectious
Sexually Transmitted Diseases
Benign lesions of seminal or prostatic vesicles
Benign urethral lesions
Urethral or prostate varicose veins
Tumors (seminal vesicles and testicles)
Benign urethral lesions
Severe high blood pressure
-Causes of hematospermia in people over 40 years of age
Urethritis, sexually transmitted infections.
Benign prostatic hyperplasia.
Seminal or prostate vesicles
Benign urethral lesions
Papillary granulomas and adenomas.
Varicose veins prostatic urethra.
Severe high blood pressure.
In a first evaluation of the patient, it would be necessary to rule out causes of pseudohematospermia: hematuria, bleeding from the couple or melanospermia (dark-black coloration of semen, as a result of prostatic metastasis of a melanoma).
Once the hematospermia is confirmed, in addition to age, the duration, the appearance of symptoms and associated risk factors are evaluated. Self-limited or single episodes are more frequently related to benign causes than persistent ones (> 1 month).
Symptoms such as ejaculatory pain, dysuria and fever often translate into inflammatory, infectious or obstructive causes.
Others, such as incontinence, nocturia or retention, focus more on structural aetiology.
And if any share risk factors, such as weight loss, hematuria, night sweats, adenopathy or bone pain, we would suspect a neoplasia.
It is essential to include in the interview aspects such as sexual behaviour or recent local instrumentation.
Physical examination should begin with taking blood pressure and temperature. In the abdomen we will assess the presence of hepatomegaly, masses, inguinal adenopathies or petechial lesions.
In the genital area, the penis, scrotum, epididymis and testicle should be explored, looking for tumours, structural alterations, pain or traumatic signs.
And in case of suspicion of a prostatic problem, an ultrasound scan for prostatic evaluation (size, tumours and pain).
Main laboratory tests, in case of hematospermia:
Urine analysis and culture
Urogenital tract infection
Urinary tract neoplasia
Urethral exudate culture
Sexually transmitted infection
Semen analysis and culture
To rule out pseudohematuria and infection of sperm pathways
Blood tests and serologies
Systemic and infectious origin
Transrectal ultrasound, scrotal:
It is used to evaluate structures such as the prostate, seminal vesicle, spermatic cord and testicles.
It identifies up to 92% of the diseases related to hematospermia, such as lithiasis, cysts, varicose veins, inflammatory changes, etc. It can be used as a guide for both diagnostic (biopsy) and therapeutic interventions.
Magnetic Resonance Imaging (MRI):
It is used for cases in which ultrasound has not been able to identify the origin of hematospermia. It can have up to 100% sensitivity.
Computed Tomography (CT):
Indicated to assess pelvic and/or abdominal structures, in which structural or neoplastic origin is suspected.
Urethrocystoscopy, in suspicion of urethral or vesical lesions.
Recurrent or persistent hematospermia.
Elevated PSA (> 4 ng/ml).
Concomitant hematuria or pyuria.
Risk factors: weight loss, hematuria, night sweats, adenopathy or bone pain.
Structural Symptoms: pain, incontinence, nocturia, or retention.
The majority of cases are self-limited and of good prognosis, therefore, our initial intervention would be to reassure and inform especially young patients, without risk factors and faced with a single episode of hematospermia.
In cases of suspicion of localized infection, an empirical antibiotic treatment can be started after culture collection, which will be re-evaluated when the results arrive.
Nonsteroidal anti-inflammatory drugs (NSAIDs) in case of pain, and suspected inflammatory origin.
Hematospermia due to instrumental techniques, except for coagulation problems, is usually self-limited to a few weeks.
In general, inflammatory and traumatic causes predominate in young people. At older ages, tumours should be ruled out.