Blood in semen (Hematospermia)

Having blood in semen might not be of big importance to many readers, however it can be an agonising issue to those who undergo this issue.

There can be a variety of medical conditions that lead to hematospermia, mostly are related to infection of urinary tract, ejaculatory duct or seminal vesicles or a combination of all of them. However it can occur in cancer related cases that involve the genitourinary system. Most of the time the condition will resolve on it’s own or following a short course of antibiotic treatment.

Having blood in the semen has been noted in patients who underwent recent medical procedures like prostate biopsy, catheterisation or tras-urethral cystoscopy.

Is the condition common among men?

The condition have been reported by Hippocrates, however and despite being documents and described for many centuries; prevalence of blood in semen is unknown, reason for that is it may go undetected for many men, many other men who notice to have blood or trace of blood on ejaculation might fail to seek medical attention, following that the condition might resolve or they might even deviate from asking for medical support.

Nevertheless, patients who underwent recent surgical procedures like prostate biopsy (Transrectal rectal ultrasound guided biopsy TRUS) may suffer from hematospermia which has been reported to range between 36.6% -84% in some studies.

What are possible causes of blood in semen?

  1. Urinary tract issue: inflammation of the urethra can lead to passing blood or trace of blood with the semen. In addition, having abnormal growth, cyst or even narrowing “stricture” of the urethra can sometimes lead to hematospermia.
  2. Seminal vesicle and ejaulatory ducts: having cysts or lesions within the seminal vesicles have shown to be the most common reason for persistent blood in semen in a number of studies.
  3. Prostate related issues: Patients who suffer from benign prostatic hyperplasia can have been reported to have hematospermia. Otherwise despite not being common, prostatic cancer patients may suffer from blood trace in semen. A high percentage of those patients will suffer from bloody semen following TRUS as mentioned earlier. In addition, prostate inflammation “prostatitis” patients may have similar outcomes.
  4. Reasons related to infection: Genitourinary tract infection with herpes simplex virus, chlamydia, enterococcus faecalis, ureaplasma urealyticum tuberculosis, human immunodeficiency virus (HIV) and cytomegalovirus may have hematospermia. Some patients infected with urogenital parasites such as schistosoma might present with the same symptom.
  5. Trauma and medical intervention: Hematospermia can also occur following blunt trauma to the groins or in other cases history of admission to medical ward and undergoing catheterization or extracorporeal shock wave lithotripsy (ESWL).
  6. Miscellaneous: Other conditions that cause bleeding tendency like sickle-cell anemia, or taking blood thinners, high blood pressure, renal failure, chronic liver diseases may result in blood in semen.

How to manage this issue?

Despite having risk of malignancy among the list mentioned however we have to reassure you that risk of malignancy is low among other causes and it’s more prevalent among elder groups. Patients should also be reminded that most of the hematospermia is a self-limiting condition that resolves without or with minor medical intervention.

On the other hand, patients with prolonged history of hematospermia will require more detailed investigation

History taking: Management should start with prolonged history taking that include any recent trauma , instrumentation, bleeding disorder, medication, infection. You doctor should keep in mind a patient’s age and project it against health risk factors, younger patients are more likely to suffer from urogenital infections, while older patients with recurrent and few month history of blood in semen should be investigated properly.

Physical examination: Like other physical exams, vital signs are important in this condition, patients with raised blood pressure should be monitored and managed accordingly. Your physician should examine the testis for any unusual nodular swellings and physical examination should include digital rectal exam to inspect any nodularity in the prostate and the seminal vesicles.

Clinical investigations: Patient’s urine sample should be obtained and tested for any sign of infection or possible bleeding secondary to injury, trauma or even medical instrumentation.

In the case of an enlarged prostate, blood samples to test for Prostate Specific Antigen (PSA) should be collected. Some cases might require semen analysis and culture as well.

Imaging: Your doctor might decide to send you for further imaging in the cases of unusually enlarged prostate, feeling nodular masses or when there is no obvious possible reason to lead to this current condition. Imaging might range between urogenital ultrasound, magnetic resonance imaging (MRI), computerized tomography of the urinary system or rectal ultrasound of the prostate.

Scope: If bleeding (visible to the naked eye or not) was noted in the urine, cystoscope (scope of the urethra and the bladder) might be carried out.

Treatment options

Patients who are suspected or diagnosed with urinary tract infection should receive suitable antibiotics. Your doctor shouldn’t shy away from covering with empiric and broad spectrum antibiotics while waiting for the results.

Surgical excision of simple lesion or aspiration of cysts can be done once the diagnosis is confirmed.

Endoscopic treatment and fraction seminal vesicle stones using lasers is possible. Also using cystoscope to coagulate and stop the bleeding in the bladder or along the urethra.

Systemic related causes for hematospermia have to be managed accordingly including stop taking blood thinning medications, blood pressure control etc.

As mentioned, most blood in semen are self-limited conditions that can resolve without intervention. Thus if you noticed anything unusual it’s important to remain calm and speak to your doctor.

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