Hematospermia demystified

An anxious colleague recently came into my office and closed the door. “I think I might have prostate cancer,” he said quietly. After a moment of stunned silence, I asked him about his prostate-specific antigen (PSA) level and whether he had had a biopsy. “I haven’t had a PSA test recently, and I’ve never had a biopsy,” he replied. “What makes you think that you might have prostate cancer?” I asked. “Well,” he said, “my wife and I had sex last night, and she noticed that there was blood in my semen.”

Few things alarm a man and his partner more than seeing bloody ejaculate, a condition called hematospermia, or hemospermia. It conjures fears of cancer or a sexually transmitted disease. While it’s true that hematospermia may indicate prostate cancer or another urologic disease, that’s usually not the case. In many instances, it has no apparent cause. Just as puzzling, the condition can be limited to a single episode or can occur repeatedly over several weeks or months before disappearing completely.

Doctors have been diagnosing hematospermia for centuries — even the Greek physician Hippocrates, who lived from around 460 to 377 B.C., described it. But the true prevalence of the condition remains a mystery. A busy urologist may see several patients a year with hematospermia, but it’s likely that far more cases go unnoticed by a man or his partner during intercourse. And some cases certainly go unreported by men who’d rather not find out what ails them.

Although health care professionals can’t quantify hematospermia’s prevalence, they have been increasingly able to ascribe the condition to a particular cause, thanks to better diagnostic techniques, advances in medical imaging, and some good old-fashioned sleuthing. From there, they can either prescribe medication or another treatment, or offer an anxious patient some much-needed reassurance that the condition will resolve on its own.

Among the culprits…

Historically, doctors linked hematospermia to sexual behavior. As the authors of an article in The Journal of Urology explain, patients were “warned about excessive overindulgence and prolonged sexual abstinence.” And as recently as a decade ago, most cases (up to 70% in some studies) were diagnosed as idiopathic, meaning that they had no obvious cause. The condition, researchers believed, was “benign and self-limited.” But in 2003, thanks to improved imaging techniques, a team of researchers classified only about 15% of cases as idiopathic. The rest of the cases were attributed to dozens of other factors that they grouped into six categories, as follows.

Inflammation and infection

Inflammation of any of the organs, glands, or ducts involved in the production or storage of seminal fluid can lead to hematospermia. These include the seminal vesicles, vas deferens, epididymis, prostate, and urethra (see Figure 1 below). Inflammation can be caused by irritation or trauma; stones or calcified deposits in the prostate, seminal vesicles, bladder, or urethra; and infections with viruses, bacteria, fungi, or parasites. Sexually transmitted diseases, such as herpes, gonorrhea, and chlamydia, have also been implicated in hematospermia.

Some studies have shown that inflammation and infection are the most common causes of hematospermia in younger men (the average age of hematospermia patients is 37) and up to 39% of cases over all.

Obstruction

Obstructed ducts, such as the ejaculatory duct, and the formation of cysts in the prostate or seminal vesicles can cause hematospermia. When ducts are blocked, nearby blood vessels can dilate and rupture. An enlarged prostate, also called benign prostatic hyperplasia, pinches the urethra and can lead to hematospermia, too.

Tumors

Benign polyps and malignant tumors of the prostate, testicles, epididymis, and seminal vesicles may cause hematospermia. Men whose sole symptom is hematospermia are more likely to have prostate cancer than men who don’t have blood in their semen, but the chances are slim. A Northwestern University study of 26,126 men who underwent prostate cancer screening proves the point: among all study participants, 6.5% were diagnosed with prostate cancer. Among those who complained of hematospermia, 13.7% were diagnosed with prostate cancer. (For more details, see “Hematospermia and prostate cancer,” below.) Even though the finding is statistically significant, keep in mind that more than 86% of men with hematospermia don’t have prostate cancer. One could argue, too, that these numbers may be elevated because a screening study like this is likely to attract men at greater-than-average risk of prostate cancer.

A review of other scientific articles found 33 tumors in 931 patients with hematospermia, or 3.5%, far fewer than in the Northwestern study. Of the 33 tumors that were identified, 25 were prostate tumors. The other eight tumors were found in the seminal vesicles, testicles, and epididymis.

Vascular abnormalities

Blood vessel abnormalities in the seminal vesicles, bladder, prostate, seminal vesicles, and spermatic cord (the vas deferens and its accompanying arteries, veins, nerves, and lymphatic vessels) may be the source of bleeding.

Systemic factors

Several diseases and disorders that affect the whole body have been linked to hematospermia. These include severe hypertension (high blood pressure), a bleeding disorder called hemophilia, leukemia, and chronic liver disease.

Trauma/medical procedures

Most cases of hematospermia are probably caused, unintentionally, by medical procedures. Transrectal ultrasound prostate biopsy (TRUS-PB), which removes bits of prostate tissue to check for cancer, provokes it. The reported incidence of hematospermia following a biopsy varies between 5.1% and 89%. A recent study by Miami researchers pegged the incidence of hematospermia following TRUS-PB at 84%. On average, hematospermia lasted three and a half weeks before resolving on its own. (For more details, see “Hematospermia and TRUS-PB,” below.)

Other medical procedures, including radiation therapy, brachytherapy, transurethral resection of the prostate (for BPH), and vasectomy can bring about hematospermia, as can testicular or perineal trauma, pelvic fracture, injury during sex, and prolonged sexual abstinence.

Admittedly, reading this long list of possible causes may do little to reassure a man with bloody semen. My colleague, for example, now not only worried that he had prostate cancer, but also that he had polyps, cysts, blocked ducts, and tuberculosis, too. But if you experience hematospermia, don’t let your mind run wild. (Remember that most cases can’t be attributed to a particular cause and resolve on their own without treatment.) Instead, schedule an appointment with your doctor or urologist. If a cause can be determined, it can be treated. If no cause can be found, you’ll probably breathe a bit easier.

Detective work

Your doctor or urologist will begin by taking a detailed medical history and asking questions about your symptoms: How and when did you notice blood in your semen? Have you had a single episode of hematospermia, or has the condition been persistent? Have you had any urologic tests or a prostate biopsy recently? Have you traveled to any areas where tuberculosis is common? What medications are you taking? Have you experienced other symptoms, such as fever, unexplained weight loss, urinary problems, or pain? He or she will also ask about sexual activity.

Next, your doctor will conduct a physical exam to rule out various conditions that can cause hematospermia. He or she will take your blood pressure and temperature, feel your abdomen, examine your genitals, and perform a digital rectal exam to feel for hard spots on the prostate gland and for cysts in the seminal vesicles.

In addition, you will have a blood test, urine analysis, and urine culture. If sexually transmitted diseases are suspected, your doctor may test for them. And if there’s a chance that the blood may have come from your partner, your doctor may suggest a condom test: ejaculate is collected in a condom and then examined for blood.

Just as there is little consensus about when, or even whether, a healthy man should have a PSA test, physicians don’t always agree about when or whether patients with hematospermia should have one. Some experts say it’s necessary only in patients over age 50 unless the patient has a family history of prostate cancer. Others, including me, recommend PSA testing in all hematospermia patients over age 40 because, as I noted, it can be a sign of prostate cancer. The incidence of prostate cancer in younger men is quite low — according to the National Cancer Institute, only 0.6% of cases are diagnosed in men age 44 or younger. So, in my opinion, PSA testing before 40 probably isn’t necessary unless you have other symptoms. In an older man with a borderline-high PSA score, I would consider ordering a prostate biopsy.

Men who have persistent hematospermia, blood in the urine, or other symptoms, or who are over age 40 may have a transrectal ultrasound (TRUS) to look for abnormalities in the prostate, seminal vesicles, and other tissues. During this procedure, the doctor inserts an ultrasound probe into the rectum (see Figure 2 below). The probe emits sound waves and then “listens” for echoes as the waves bounce back off surrounding tissues (the prostate, for example).

Based on the strength, pitch, and direction of the reflected waves, a computer creates pictures of the internal anatomy (see Figure 3 below). Several studies have shown that TRUS effectively pinpoints usually benign abnormalities that can lead to hematospermia in 74% to 95% of patients. Among the findings: enlarged seminal vesicles; stones in the seminal vesicles, prostate, or ejaculatory duct; cysts; and BPH. Interestingly, no cancers were detected in these studies. Because it is so effective and minimally invasive, TRUS is the first type of imaging that should be performed.

Depending on what information TRUS yields, your doctor may recommend two other procedures: magnetic resonance imaging (MRI) and cystoscopy. Unlike TRUS, MRI can reveal bleeding in the seminal vesicles or prostate. Cystoscopy allows your doctor to examine the inside of the bladder and urethra, areas that may not show up well on MRI and TRUS, with a thin, lighted instrument called a cystoscope.

Case closed

The treatment for hematospermia, obviously, depends on the cause. Infection, for example, should be treated with antibiotics. Bleeding in the seminal vesicles, urethra, and prostate can be halted with an electric current. Any systemic problems, such as high blood pressure, should be controlled or treated. And if the amount of blood in the semen is slight, or in cases where there is only one or two episodes of hematospermia, a wait-and-see approach might be best. However, if hematospermia returns, check back with your doctor. Some doctors have found that treating chronic hematospermia with finasteride or dutasteride solves the problem, though no clinical trials have proven the medications to be effective in hematospermia patients. Others may prescribe antibiotics if they suspect asymptomatic prostatitis.

As for my colleague, I am happy to report that he is fine. He had several tests, including a TRUS, but we weren’t able to identify the cause of the bleeding. He did mention that he and his wife hadn’t had sex in quite a while, so the spotting that he saw may well have come from overly full seminal vesicles. Regardless, he hasn’t experienced any more episodes of hematospermia.

While hematospermia can certainly be frightening, it is a benign disorder in most patients. A quick visit with your doctor will probably reassure you that hematospermia is little more than a case of smoke without the fire.

Originally published March 2009; last updated April 22, 2011.