Haematospermia

Aetiology of haematospermia

Infection (in the form of prostatitis, urethritis, epididymo-orchitis): Bacterial – chlamydia, gonorrhoea, enterococcus, tuberculosis Viral – human immunodeficiency virus (HIV), cytomegalovirus (CMV), herpes simplex virus (HSV) Other – schistosomiasis Iatrogenic Post-transrectal ultrasound (TRUS) biopsy Prostate radiotherapy or brachytherapy Post-vasectomy Post-orchidectomy Malignancy Prostate Bladder Testicular Urethral Trauma Coital trauma Perineal trauma Prolonged abstinence Obstruction Ductal obstruction Cysts of seminal vesicles/Wolffian duct/utricle Calculi of seminal vesicles, ejaculatory duct, prostate, urethra Systemic disorders Hypertension Chronic liver disease Lymphoma Leukaemia Amyloidosis Bleeding disorders Idiopathic

• Make sure to differentiate haematuria or blood from partner
• Red flags
  • Age > 40
  • Recurrent or persistent
  • Prostate cancer risk factors – eg family history
  • Constitutional symptoms
• Pain on ejaculation suggests prostatitis
• Examine testes/PR

Investigations

• Urine MCS
• Urine cytology
• Sti screen
• FBC, coagulation studies
• PSA if age > 40 or any red flags

• If no cause found and doesn’t recur – reassure/ Otherwise refer to urologist

Management of Haematospermia

• Indications for Urology Referral
  • Men ≥40 years of age
  • Persistent or recurrent haematospermia
  • Suspicious digital rectal examination (DRE) findings
  • Abnormal prostate-specific antigen (PSA) results
  • Suspicion of malignancy (prostate, bladder, testicular, or urethral) based on history, examination, or investigations
  • Concurrent haematuria
  • Haematospermia despite treatment for the suspected cause

Isolated Event:

• If no underlying cause is found and haematospermia is isolated, reassurance is sufficient.
• Address patient anxiety, especially concerns about fertility and cancer risks.
• Most causes have no effect on fertility; testicular malignancy is a rare exception.

Infection:

• Initiate appropriate antimicrobials if an infection is suspected or proven.
• Empirical treatment for STIs: intramuscular ceftriaxone and oral azithromycin.
• Treatment for mild-to-moderate prostatitis or epididymo-orchitis: trimethoprim or amoxicillin with clavulanic acid.
• Refer to infectious diseases clinic for unusual infections (e.g., tuberculosis, schistosomiasis).

Iatrogenic Haematospermia:

• Counsel patients pre-procedure about haematospermia risks.
• Post-prostate biopsy haematospermia typically resolves after 20 ejaculations.
• Further investigations and treatment arranged by the urologist if malignancy is identified.

Ductal Obstruction and Cystic Abnormalities:

• Urologist may perform interventions like cystic aspiration, deroofing, or endoscopic removal of calculi.

Systemic Causes:

• Refer to appropriate specialty for systemic causes of haematospermia.

Persistent Haematospermia:

• If no cause is identified after diagnostic work-up by GP and urologist, consider 5-alpha reductase inhibitors (e.g., finasteride, dutasteride).
• Useful in elderly patients with benign prostatic bleeding; may take six months to see improvement.
• For younger men with persistent idiopathic haematospermia, consider one month of doxycycline treatment.

Key Points

• Haematospermia can be an anxiety-provoking symptom for men.
• Most cases are benign and self-limiting but may occasionally indicate underlying malignancy.
• Systematic evaluation is warranted to rule out serious conditions like prostate cancer.
• Red flags include:
  • Age ≥40 years
  • Recurrent or persistent haematospermia
  • Prostate cancer risk factors (e.g., positive family history, African heritage)
  • Constitutional symptoms (e.g., weight loss, anorexia, bone pain)
• Management depends on the underlying cause, with reassurance needed for isolated cases.