Case Presentation
A 56-year-old male with no significant past medical history presents to Urgent Care with a complaint of a urinary tract infection. He is brought back by the medical assistant who obtains a urine sample. Upon evaluation by the provider, he discloses that he suspects he has a urinary tract infection because he has noted blood when he ejaculates. He states that approximately three weeks ago he had self-performed a manual release, and noted blood in the sperm. He had a small amount of blood spontaneously drain from his penis for about a day, but then the symptoms resolved. He continued to self-perform manual releases without more episodes of hematospermia, until several days prior to this visit, when the bloody sperm recurred. The patient states this time he had copious blood with clots draining from his urethra for several hours after the episode but has not noted blood since. He delayed seeking medical attention because he was embarrassed. He is now afraid to masturbate again. He denies any trauma to the genitals before or during masturbation. He has no dysuria, urgency, frequency, abdominal pain, penile or scrotal pain, fever, or chills. He has noted no rashes or lesions on his penis. He is not on aspirin or blood thinners. He denies intercourse with males or females in years and has never had an STI that he is aware of.
His vital signs are normal.
The urine sample obtained by the MA is normal.
His physical exam, including a genital exam is normal.
Discussion
Hematospermia, or blood in the ejaculate, is not a common complaint seen in Urgent Care or primary care.[1] It is actually very rare in any setting. The true incidence is not known likely due to under reporting Although frightening, in most cases the cause is benign.[2] Because it is so rare, there is little research available.
It is extremely important to take a thorough history to delineate exactly where the blood is coming from. Renal, bladder, and urethral blood could easily be confused with hematospermia by the patient. As the work up is vastly different, every effort needs to be made to narrow the source of bleeding.
The most common causes of hematospermia are post-procedural. This would include prostate biopsy, radiation treatment of the prostate, and vasectomy. Non-procedural trauma is also possible. Infections, including STI’s, malignancy, infiltrative and anatomic disorders, and exogenous or endogenous bleeding disorders may also contribute to hematospermia. Frequent daily ejaculation may also be a cause.
In most cases, especially in men under 40, often the cause is benign or never found, and usually resolves spontaneously without treatment. In a case series by Zhao in 2011, 270 men with hematospermia underwent transrectal ultrasound. No man < age 40 had cancer, and only 8 of 126 patients (6.3%) > age 40 had carcinoma (five prostate, two seminal vesicle, and one bladder).[3]
Evaluation of men with hematospermia should include a detailed history and a careful physical exam. A urinalysis should be performed on all patients. A urine culture should be done if the urinalysis is consistent with pyuria. Patients who have symptoms of urethritis, but no pyuria should have testing for STIs including gonorrhea and chlamydia. Trichomonas should also be considered.
Semen analysis is generally of little value except when there is a question of whether there is actually blood in the semen, or if the patient has traveled to an area in which schistosomiasis is endemic. Microscopic evaluation can detect blood and schistocytes if present.
Rare cases may require a transrectal ultrasound of the prostate, MRI of the prostate, or a referral to a urologist. Prostatic-specific antigen testing is not necessary in these patients. In most cases, a clear cause will not be found, and the symptoms will resolve spontaneously. Treatment is rarely required, and reassurance is all that is necessary.
Case Resolution: This patient requested to see a urologist. Gonorrhea and Chlamydia testing were negative, ultrasound was negative, and the patient’s symptoms did not recur. No further evaluation or follow up was recommended.
[1] Tintinalli J, et. al. Tintinalli’s Emergency Medicine, 9th Ed. 2020. Pp. 598
[2]https://www.uptodate.com/contents/hematospermia?search=hematospermia&source=search_result&selectedTitle=1~35&usage_type=default&display_rank=1#H1 accessed online 12/11/22
[3] Zhao H, Luo J, Wang D, Lu J, Zhong W, Wei J, Chen W. The value of transrectal ultrasound in the diagnosis of hematospermia in a large cohort of patients. J Androl. 2012;33(5):897. Epub 2011 Apr 21. Accessed online 12/11/22
