Evaluation and treatment of hematospermia

Hematospermia can be a distressing symptom for patients, but most cases are effectively managed by a primary care physician. Although the condition is usually benign, significant underlying pathology must be excluded by history, physical examination, laboratory evaluation, and, in select cases, other diagnostic modalities. In men younger than 40 years without risk factors (e.g., history of cancer, known urogenital malformation, bleeding disorders) and in men with no associated symptoms, hematospermia is often self-limited and requires no further evaluation or treatment other than patient reassurance. Many cases are attributable to sexually transmitted infections or other urogenital infections in men younger than 40 years who present with hematospermia associated with lower urinary tract symptoms. Workup in these patients can be limited to urinalysis and testing for sexually transmitted infections, with treatment as indicated. In men 40 years and older, iatrogenic hematospermia from urogenital instrumentation or prostate biopsy is the most common cause of blood in the semen. However, recurrent or persistent hematospermia or associated symptoms (e.g., fever, chills, weight loss, bone pain) should prompt further investigation, starting with a prostate examination and prostate-specific antigen testing to evaluate for prostate cancer. Other etiologies to consider in those 40 years and older include genitourinary infections, inflammations, vascular malformations, stones, tumors, and systemic disorders that increase bleeding risk.