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Saturday, August 23, 2025

Blood in semen


Blood in Semen (Hematospermia)

Introduction

Hematospermia is defined as the presence of visible blood in semen. It may be alarming for patients, but in most cases it is not dangerous.

  • In men under 40 years, it is usually benign, often due to infection or inflammation.

  • In men over 40 years, recurrent or persistent hematospermia may warrant investigation for prostate or seminal vesicle disease.

Pathophysiology

Semen is produced by:

  • Testes (sperm production).

  • Seminal vesicles, prostate, bulbourethral glands (fluid contribution).

Blood may enter semen from any structure along this pathway, due to infection, inflammation, trauma, or malignancy.

Causes of Hematospermia

1. Infective / Inflammatory (most common)

  • Prostatitis (prostate infection).

  • Urethritis (gonorrhea, chlamydia, other STIs).

  • Epididymitis, orchitis.

  • Seminal vesiculitis.

  • Tuberculosis (genitourinary TB in endemic areas).

2. Structural / Obstructive

  • Cysts or calculi in prostate or seminal vesicles.

  • Benign prostatic hyperplasia (BPH).

  • Ejaculatory duct obstruction.

3. Neoplastic (rare but serious)

  • Prostate cancer.

  • Seminal vesicle or bladder cancer.

  • Testicular tumors.

4. Traumatic / Iatrogenic

  • Prostate biopsy or surgery.

  • Vigorous sexual activity or prolonged abstinence.

  • Trauma to genitals.

5. Vascular / Systemic

  • Hypertension.

  • Bleeding disorders (hemophilia, thrombocytopenia).

  • Anticoagulant therapy (warfarin, heparin, DOACs).

6. Idiopathic (no cause found)

  • Up to 30% of cases have no identifiable cause.

Clinical Features

  • Discolored semen: pink, red, brown, or rust-colored.

  • May be single episode or recurrent.

  • Often painless.

Associated symptoms may suggest cause:

  • Dysuria, frequency, urgency: UTI or prostatitis.

  • Painful ejaculation, pelvic/perineal pain: Prostatitis or seminal vesiculitis.

  • Hematuria (blood in urine): Bladder or prostate disease.

  • Systemic symptoms: Fever (infection), weight loss (cancer).

  • History of trauma or procedure: Likely benign and self-limited.

Diagnostic Approach

1. History

  • Age, frequency, duration of hematospermia.

  • Associated urinary or sexual symptoms.

  • History of STIs, TB, urological procedures.

  • Medications (anticoagulants).

  • Family history of prostate cancer.

2. Examination

  • General: BP, signs of bleeding disorder.

  • Genital exam: testicular lumps, tenderness.

  • Digital rectal examination (DRE): prostate size, nodules, tenderness.

3. Investigations

  • Urinalysis + urine culture: UTI, hematuria.

  • Semen analysis and culture: Infection.

  • STI screening: Gonorrhea, chlamydia, HIV, syphilis.

  • PSA (Prostate Specific Antigen): Prostate cancer screening (>40 years).

  • Blood tests: CBC, coagulation profile.

  • Transrectal ultrasound (TRUS): Prostate and seminal vesicles (cysts, stones, tumors).

  • MRI pelvis: Complex or persistent cases.

  • Cystoscopy: If hematuria or bladder pathology suspected.

Management and Treatment

Treatment depends on cause. Most cases resolve spontaneously.

A. General Measures

  • Reassurance (especially in young men with single episode).

  • Abstain from sex for a few days if linked to trauma.

  • Manage risk factors: control hypertension, review anticoagulants.

B. Pharmacological Therapy

1. Infective Causes

  • Prostatitis, epididymitis, seminal vesiculitis:

    • Ciprofloxacin 500 mg orally twice daily × 2–4 weeks.

    • Alternative: Trimethoprim–sulfamethoxazole 160/800 mg orally twice daily × 2–4 weeks.

  • STIs:

    • Gonorrhea: Ceftriaxone 500 mg IM single dose + Doxycycline 100 mg orally twice daily × 7 days (if chlamydia not excluded).

    • Chlamydia: Doxycycline 100 mg orally twice daily × 7 days.

  • Tuberculosis (genitourinary):

    • Standard anti-TB therapy (Isoniazid, Rifampicin, Ethambutol, Pyrazinamide).

2. Prostatic Enlargement (BPH)

  • Tamsulosin 0.4 mg orally once daily.

  • Finasteride 5 mg orally once daily.

3. Pain / Inflammation

  • NSAIDs: Ibuprofen 400 mg orally every 8 h for 5–7 days.

C. Procedural / Surgical Treatment

  • Cysts or stones: Endoscopic removal.

  • Persistent hematospermia with obstruction: Transurethral resection of ejaculatory duct (TURED).

  • Cancer: Prostatectomy, radiotherapy, chemotherapy depending on stage.

Complications

  • Anxiety, distress, relationship problems.

  • Missed underlying cancer (rare but important).

  • Chronic prostatitis or recurrent infections.

Prognosis

  • Young men with isolated episodes: Excellent, usually benign.

  • Older men (>40 years): Requires careful evaluation, but most still benign.

  • Persistent or recurrent cases: Often linked to treatable infection or BPH; rarely cancer.

Patient Education

  • Blood in semen is rarely due to cancer, especially in young men.

  • Often related to infection, inflammation, or minor trauma.

  • See a doctor if:

    • Persistent or recurrent hematospermia.

    • Associated with blood in urine, urinary symptoms, pain, fever, weight loss.

    • Age >40 years.

  • Safe sex practices reduce risk of STIs.

  • Complete antibiotics if prescribed.




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