Section Author: Jon Rees
Review Date: September 2017
The management of a man with haemospermia (or haematospermia) is another common dilemma for primary care clinicians.
Patients are often very worried by haemospermia. It is a relatively common symptom, but whilst many general practitioners see it as of low clinical concern, patients are often extremely concerned by it as a ‘harbinger of malignancy’. A full assessment enables the GP both to appropriately identify those patients at risk of significant pathology, and equally to ensure the patient is reassured that this condition has been taken seriously.
Haemospermia occurs most commonly in a younger population (mean age of patients is 37 years). Most episodes in younger men are due to inflammatory or infectious causes, and therefore patients under the age of 40 with a single episode of haemospermia can safely be reassured that this is a common, benign and generally self-limiting symptom. They should seek further advice only if they continue to experience haemospermia.
- Think of prostatitis or epidymitis as possible causes. It is worth specifically enquiring about perineal or testicular discomfort. Always send an MSU - it is also possible to send expressed prostatic secretions or seminal fluid for microscopy and culture. If in doubt treat with a 2 week course of an appropriate antibiotic e.g. Ciprofloxacin 500mg bd. It may be worth taking a sexual history and test if indicated for a sexually transmitted infection.
- Examine the patient. All men with haemospermia should have a testicular examination (rarely a presenting symptom of testicular cancer) and a digital rectal examination of the prostate.
- Younger patients with persistent unexplained haemospermia should be referred to a Urologist for assessment. This is particularly indicated if they have perineal discomfort or painful ejaculation. The single most important diagnostic tool is a transrectal ultrasound of the prostate and seminal vesicles, looking particularly for calculi in the prostate or dilation / cysts of the seminal vesicles or ejaculatory ducts. Other investigations such as flexible cystoscopy or CT scans may also be required.
- Patients over the age of 40 are at increased risk of significant pathology. The most important condition that should be considered is prostate cancer. In a large prospective prostate cancer screening study performed in the United States, prostate cancer was detected in 6.5% of men who entered the screening study, but in 13.7% of those men who reported having experienced haemospermia. The incidence of haemospermia in this population of men over 50 was only 0.5%, so assessing patients with haemospermia for their risk of prostate cancer is not going to greatly increase the number of men investigated.
- All patients with haemospermia over the age of 40 should have a digital rectal examination and be counselled regarding a PSA test. The risk of prostate cancer is increased in the presence of persistent haemospermia and with increasing age. If both DRE and PSA are normal patients can be reassured, and only referred to a Urologist if symptoms are persistent and bothersome.
- Haemospermia is normal after prostate biopsy. A recent study has looked at the incidence of haemospermia after prostate biopsy. The study found that most men (84%) experienced haemospermia, with a mean duration of 3.5 weeks. The mean number of ejaculations before the complete resolution of haemospermia was 8. Haemospermia often takes longer than rectal bleeding or haematuria to settle after biopsy. Patients with persistent haemospermia after biopsies should therefore be reassured this is relatively common, and only treated if there is clinical suggestion of infection.
- There may be a link with hypertension. Some studies suggest a link between haemospermia and hypertension, and there are case reports of haemospermia secondary to severe uncontrolled hypertension. All patients with haemospermia should therefore have their blood pressure checked.
- Consider other systemic causes of haemospermia. These include haemophilia, leukaemia, lymphoma, liver disease and other causes of clotting abnormality. Consider carrying out a full blood count, liver function tests and clotting screen in patients with persistent idiopathic haemospermia.
Healthcare Professional Links
NICE Clinical Knowledge Summary for Haemospermia: http://cks.nice.org.uk/haematospermia#!scenario