Hematospermia, the presence of blood in the ejaculate, is a symptom that often causes significant alarm. While the sight of blood in semen is frightening, in the vast majority of cases, the underlying cause is benign and self-limiting. The condition indicates bleeding at some point along the complex male reproductive and urinary tract, from the testes and epididymis to the prostate and urethra. A systematic evaluation is necessary to identify the source of the bleeding and rule out the few, but serious, conditions that may be responsible.
Defining Hematospermia and Common Characteristics
Hematospermia involves the visible presence of blood, which can manifest in several ways depending on the volume and age of the bleeding. Fresh bleeding typically results in pink or bright red coloration, while older, oxidized blood appears reddish-brown or rust-colored. Sometimes, the blood may present as small, dark, clot-like specks mixed within the ejaculate.
For many men, particularly those under the age of 40, hematospermia is a transient, isolated symptom that resolves spontaneously within a few weeks to months. This self-limiting pattern suggests an inflammatory or minor vascular cause, which often requires no specific intervention beyond simple observation.
Underlying Causes and Associated Risk Factors
The origins of hematospermia are diverse, involving any structure responsible for producing, storing, or transporting semen. The most common causes involve inflammation or infection within the genitourinary tract, such as prostatitis (prostate inflammation), epididymitis (inflammation of the coiled tube behind the testicle), or urethritis. Sexually transmitted infections (STIs) like Chlamydia or Gonorrhea are also known infectious agents that can cause inflammation and bleeding.
Structural or vascular issues can also lead to blood in the semen due to fragility or obstruction along the duct system. Examples include seminal vesicle cysts, benign prostatic hyperplasia (BPH), or small blood vessel malformations like urethral polyps. Increased pressure from ejaculatory duct obstruction can cause mucosal blood vessels to rupture, leading to recurrent bleeding.
External factors often provide a simple explanation, such as trauma to the genitals, perineum, or pelvis, which may occur during vigorous sexual activity or cycling. Iatrogenic causes, resulting from medical procedures, are common, particularly following a prostate biopsy, which can cause hematospermia for several weeks. Less frequently, systemic conditions like uncontrolled hypertension, liver dysfunction, or inherited bleeding disorders can impair clotting mechanisms.
Malignancy, while the most concerning possibility, is a rare cause of hematospermia, especially in younger men. When cancer is the source, it is typically prostate cancer, generally seen in men over 40 years old, often accompanied by other symptoms or risk factors.
Medical Evaluation and Diagnostic Procedures
The medical evaluation begins with a detailed patient history to assess the duration of the symptom, the appearance of the blood, and the presence of associated symptoms like fever, pain, or difficulty urinating. A thorough physical examination is performed, including a check of vital signs for hypertension and a digital rectal examination (DRE) to palpate the prostate and seminal vesicles for inflammation or suspicious nodules.
Initial laboratory testing involves a urinalysis and urine culture to check for urinary tract infections or coexisting hematuria (blood in the urine). Testing for sexually transmitted infections is commonly performed, especially in younger men where infection is the leading cause. For men aged 40 years or older, or those with persistent symptoms, a prostate-specific antigen (PSA) blood test is often included to screen for prostate cancer.
If the cause remains unclear, or if the hematospermia is persistent, imaging studies are pursued. Transrectal ultrasonography (TRUS) is often the first imaging modality used, providing clear visualization of the prostate, seminal vesicles, and ejaculatory ducts. This allows for the detection of cysts, calculi (stones), or inflammatory changes. Magnetic resonance imaging (MRI) of the pelvis may be used if the TRUS is inconclusive or if further detail is required.
Treatment Approaches and Prognosis
Treatment for hematospermia is directed specifically at the underlying cause identified during the diagnostic workup. If a genitourinary infection is confirmed, a short course of appropriate antibiotics, such as a fluoroquinolone, is typically prescribed to resolve the inflammation and bleeding. For cases linked to systemic conditions, management focuses on controlling the underlying disorder, such as regulating hypertension or adjusting anticoagulant medications.
When a specific structural issue is found, such as a large seminal vesicle cyst or an ejaculatory duct obstruction, focused interventions may be necessary. Procedures like transurethral resection of the ejaculatory ducts or endoscopic removal of calculi can resolve the obstruction and alleviate the bleeding. For many men with a single episode and no other symptoms, treatment consists simply of reassurance and watchful waiting, as the symptom is self-limiting.
Patients should recognize “red flags” that signal a potentially more serious issue requiring aggressive investigation:
- Hematospermia that persists beyond two months.
- Is recurrent.
- Is accompanied by systemic symptoms like unexplained weight loss or fever.
- Occurs in a man over 40 to 50 years of age.
The overall prognosis for hematospermia is excellent, as the condition is benign in the vast majority of cases.