Differentiate haematospermia from pseudo-haematospermia.
Red flags:
Age >40
recurrent/persistent haematospermia
prostate cancer risk factors (e.g., family history, African heritage)
constitutional symptoms (weight loss, anorexia, bone pain).
Identify common aetiologies
STI symptoms
urinary tract infections
recent urological procedures
trauma
Physical Examination:
Check blood pressure and temperature.
Genital examination for penile, testicular, and scrotal abnormalities.
Digital rectal examination (DRE) for prostate abnormalities (carcinoma, prostatitis).
Systems review for systemic disease signs.
Investigations
Basic tests:
Urine microscopy, culture and sensitivity (MCS).
Urine cytology.
Full blood count and coagulation studies.
STI testing (urine nucleic acid amplification tests).
Prostate-specific antigen (PSA) assay for men >40 or with abnormal DRE.
Special tests for tuberculosis/schistosomiasis (acid-fast bacilli and parasites in urine/semen).
Management and Referral
Management: Dependent on underlying cause.
Urology Referral Indications:
Men ≥40 years of age.
Persistent/recurrent haematospermia.
Suspicious DRE findings or abnormal PSA.
Suspected malignancy.
Concurrent haematuria.
Potential Further Investigations by Urologist:
Transrectal ultrasound (TRUS).
Scrotal ultrasound.
MRI or CT for pelvic detail.
Cystoscopy for bladder and urethral pathology.
Management Overview of Haematospermia
Reassurance: If no underlying cause is found and haematospermia is an isolated event, reassurance is key. Reassurance can be challenging, particularly with anxious patients, as they often worry about fertility and cancer risks. Most cases do not impact fertility, and malignancy is rare.
Empirical Treatment for Suspected Infection:
For STIs: Intramuscular ceftriaxone plus oral azithromycin.
For mild-to-moderate prostatitis or epididymo-orchitis related to UTI: Trimethoprim or amoxicillin with clavulanic acid (good prostate penetration).
Unusual Infections:
Referral to infectious diseases specialists for infections like tuberculosis or schistosomiasis.
Iatrogenic Haematospermia:
Typically resolves after 20 ejaculations post-prostate biopsy.
Pre-procedure counselling on haematospermia risk is crucial.
Management of Malignancy:
Further investigations and treatment by a urologist.
Ductal Obstruction/Cystic Abnormalities:
Urologist intervention options include cystic aspiration, deroofing, or endoscopic removal of calculi.
Systemic Causes:
Referral to appropriate specialists.
Persistent Idiopathic Haematospermia:
Option for treatment with 5-alpha reductase inhibitors (finasteride or dutasteride), reducing VEGF expression and sub-urethral vessel microdensity. Note: Effects may take up to six months, especially useful for elderly patients with benign prostatic bleeding.
For younger men with persistent idiopathic haematospermia, a one-month trial of doxycycline is reasonable.
Key Points
Haematospermia, although alarming, is generally benign and self-limiting.
Thorough evaluation is crucial to rule out malignancy, especially in men ≥40 years, those with recurrent or persistent symptoms, or prostate cancer risk factors.
Red flags guide referral and management, with specialist involvement necessary in certain cases.
Treatment and management depend on the identified cause, focusing on resolving infections, managing benign causes, or appropriate specialist referral for complex cases.
