Clinical Approach to Hematospermia
Step-wise approach:
- Is it real HS?
- Partner bleeding
- Post-ejaculation bleeding from prostatic hemangioma.
- Melanospermia: melanin deposition in SV in melanoma.
- Is it functional?
- Long abstinence.
- Frequent ejaculation.
- Is it related ti direct avoidable cause?:
- Drugs:[aspirin, anticoagulant, atomoxitine]
- Medical instrumentation:
- Common:
- TRUS-B
- Injection of hemmorhoids
- Pelvic radiotherapy
- Post-orchiectomy
- ESWL stone lower ureter
- Uncommon:
- Brachytherapy
- HIFU
- Post-vasectomy
- Uro-pathology:
- >40 yrs:
- Increased risk of prostate cancer.
- PCa in 1% of cases
- Surveillance for PCa is needed.
- < 40 yrs:
- Infection: [TB, shistosoma, STD]
- Inflammation:
- Traumatic: perianal or genital, iatrogenic, or duct evacuator.
- Congenital: cysts
- Is there systemic cause?:
- Hypertension: specially (uncontrolled, with proteinuria, high s. creatinine)
- Hematologic disease: e.g. lymphoma, leukemia, or bleeding disease.
- Chronic liver disease
- Idiopathic:
- Mostly SV
Diagnostic Work-Up
- Laboratory
- “Condom Test”
- STD survey
- Urine analysis
- Urine Culture
- Urethral Swap
- Semen analysis and culture
- Prostatic excretion culture
- Coagulation profile
- Acid-fast bacilli in urine, semen and prostatic excretion.
- PSA
- Imaging
- TRUS
- CT
- MRI
- X-ray based (all are old, some are obsolete):
- Plain pelvic
- IVP
- Vasography
- S. Vesiculogrpahy
- Vaso-Vesical Vesiculogrpahy
- Diagnostic Cystoscopy.
Therapeutic options
- Exclusion of cancer (prostate, bladder, SV, testicular, urethral)
- Surveillance of PCa (hematospermia increase risk of PCa):
- Patients with family history
- High risk groups; African-American
- Reassurance (in most cases; idiopathic, drug related, traumatic)
- Medical treatment:
- Antibiotics (culture is not a guide, and negative culture is not sensitive)
- Targeted (chlamydia, bacteroids)
- Tetracycline
- metronidazole
- Empiric
- 5-flouroquinolone, e.g. ciprocin
- Co-trim
- Doxycycline
- Shistosoma
- Prazequantel
- Anti-tubercolus
- Anti-viral (herbes symblix)
- Finasteride
- Anti-fibrinolytic
- Other medical treatment according to the condition (antihypertensives)
- Surgical
- Aspiration of the cyst; by US or CT
- Un-roofing of seminal or prostatic cyst
- Excision of SV cysts; open or laparoscopic
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Ahmed Bakr, MD, FEBU
Egypt
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