Clinical Approach to Hematospermia

Step-wise approach:

1. Is it real HS?
• Partner bleeding
• Post-ejaculation bleeding from prostatic hemangioma.
• Melanospermia: melanin deposition in SV in melanoma.
2. Is it functional?
• Long abstinence.
• Frequent ejaculation.
3. Is it related ti direct avoidable cause?:
1. Drugs:[aspirin, anticoagulant, atomoxitine]
2. Medical instrumentation:
1. Common:
1. TRUS-B
2. Injection of hemmorhoids
3. Pelvic radiotherapy
4. Post-orchiectomy
5. ESWL stone lower ureter
2. Uncommon:  
1. Brachytherapy
2. HIFU
3. Post-vasectomy
4. Uro-pathology:
1. >40 yrs:
• Increased risk of prostate cancer.
• PCa in 1% of cases
• Surveillance for PCa is needed.
2. < 40 yrs:
• Infection: [TB, shistosoma, STD]
• Inflammation:
• Traumatic: perianal or genital, iatrogenic, or duct evacuator.
• Congenital: cysts
5. Is there systemic cause?:
• Hypertension: specially (uncontrolled, with proteinuria, high s. creatinine)
• Hematologic disease: e.g. lymphoma, leukemia, or bleeding disease.
• Chronic liver disease
6. Idiopathic:
• Mostly SV

Diagnostic Work-Up

1. Laboratory
1. “Condom Test”
2. STD survey
3. Urine analysis
4. Urine Culture
5. Urethral Swap
6. Semen analysis and culture
7. Prostatic excretion culture
8. Coagulation profile
9. Acid-fast bacilli in urine, semen and prostatic excretion.
10. PSA
2. Imaging
1. TRUS
2. CT
3. MRI
4. X-ray based  (all are old, some are obsolete):
1. Plain pelvic
2. IVP
3. Vasography
4. S. Vesiculogrpahy
5. Vaso-Vesical Vesiculogrpahy
3. Diagnostic Cystoscopy.

Therapeutic options

1. Exclusion of cancer (prostate, bladder, SV, testicular, urethral)
2. Surveillance of PCa (hematospermia increase risk of PCa):
1. Patients with family history
2. High risk groups; African-American
3. Reassurance (in most cases; idiopathic, drug related, traumatic)
4. Medical treatment:
1. Antibiotics (culture is not a guide, and negative culture is not sensitive)
1. Targeted (chlamydia, bacteroids)
2. Tetracycline
3. metronidazole
2. Empiric
1. 5-flouroquinolone, e.g. ciprocin
2. Co-trim
3. Doxycycline
3. Shistosoma
1. Prazequantel
4. Anti-tubercolus
5. Anti-viral (herbes symblix)
5. Finasteride
1. Anti-fibrinolytic
6. Other medical treatment according to the condition (antihypertensives)
7. 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