Hematospermia

1. Epidemiology
   1. Age under 40 years old most common
2. Causes: Common
   1. Behavioral
      1. Excessive masturbation
      2. Rigorous sexual intercourse
      3. Prolonged sexual abstinence
   2. Infectious (40% of cases)
      1. Epididymitis
      2. Prostatitis
      3. Rare case reports of Echinococcus, Tuberculosis, schistosoma
      4. Urinary Tract Infection pathogens have also been implicated
      5. Sexually Transmitted Disease
         1. Chlamydia
         2. Gonorrhea
         3. HSV I and II Urethritis
         4. Urethral HPV
   3. Structural causes
      1. Benign Prostatic Hyperplasia (BPH)
   4. Trauma
      1. Prostate, Urethral, penile or even Hemorrhoidal procedures (esp. Prostate biopsy)
3. Causes: Uncommon
   1. Genitourinary Tumors (e.g. Bladder Cancer, Prostate Cancer, Testicular Cancer)
   2. Prostatic stones, polyps, or cysts
   3. Urethral strictures or fistula
   4. Bleeding Disorders
   5. Vascular lesions or AV Malformations (e.g. ProstateVarices)
   6. Uncontrolled Severe Hypertension
4. Risk Factors: More serious underlying Hematospermia cause
   1. Age over 40 years
   2. History of cancer or significant cancer risk
   3. Known urologic structural abnormality
   4. Bleeding Disorder
   5. Trauma
5. History
   1. Number of episodes and exacerbating factors (e.g. intercourse)
   2. STD exposure
   3. Systemic symptoms (fever, weight loss, Night Sweats)
   4. Bleeding Disorder
   5. Pain
      1. Dysuria
         1. Urethritis
         2. Urinary Tract Infection
         3. Prostatitis
      2. Painful Bladder distention
         1. Cystitis
      3. Painful ejaculation
         1. Prostatitis
         2. Ejaculatory duct obstruction
   6. Voiding difficulty (double voiding, hesitancy, decreased stream)
      1. Benign Prostatic Hyperplasia (BPH)
      2. Bladder neck obstruction
      3. Urethral stricture
      4. Cystitis
6. Exam
   1. Vital signs (temperature, Blood Pressure, Heart Rate)
   2. Complete genitourinary exam
      1. Include inguinal lymph node exam
      2. Testicular mass
      3. Epididymitis findings
      4. Signs of Genitourinary Trauma including at Urethral meatus
   3. Rectal exam with Prostate exam
7. Labs
   1. Urinalysis and Urine Culture
   2. Prostate Specific Antigen (PSA) in age over 40 years old
   3. Sexually Transmitted Disease tests
      1. Chlamydia PCR
      2. Gonorrhea PCR
   4. Additional labs to consider for persistent or recurrent symptoms or risk factors as above
      1. Coagulation studies (PT/INR, PTT, Complete Blood Count)
      2. Urine cytology
8. Differential Diagnosis
   1. Hematuria
   2. Blood from sexual partner (evaluate by using Condom with intercourse)
   3. Melanospermia (very rare)
      1. Associated with Melanoma metastatic to Prostate
9. Management: Urology referral indications
   1. Recurrent or persistent high volume Hematospermia
   2. Hematospermia with unexplained genitourinary pain or voiding difficulty
   3. Abnormal history, exam, labs or suspected structural abnormality
10. Management: Empiric therapy trials
    1. Observation without treatment
       1. Anticipate resolution within 2-3 weeks and with 10 or more ejaculations
    2. Consider two weeks of empiric antibiotics for Epididymitis or Prostatitis
       1. Trimethoprim-Sulfamethoxazole
       2. Doxycycline
       3. Ciprofloxacin or Levaquin
    3. Consider alpha blocker trial of 4-6 weeks if Benign Prostatic Hyperplasia (BPH) suspected
       1. Terazosin (Hytrin)
       2. Tamsulosin (Flomax)
11. References
    1. Ahmad (2007) J Urol 177(5): 1613-8
    2. Kumar (2006) Ann R Coll Surg Engl 88(4): 339-42
    3. Stefanovic (2009) Am Fam Physician 80(12): 1421-28