Most men have an ejaculate (the fluid that contains the sperm) that is white and slightly cloudy. When it turns red, it is a frightening occurrence. Hematospermia, or blood in the ejaculate, is a symptom that provokes great anxiety in patients due to fears of malignancy or sexually transmitted diseases. For most men, hematospermia is not a serious, life-threatening condition.
One could think of blood in the semen in almost the same way one would think of blood in nasal mucus when one has a bad cold or sinus infection. It certainly is a sign of problems, but it’s nothing to panic about. Seeking a medical opinion is highly recommended in any instance.
Most men with hematospermia usually report brownish to red discoloration of the ejaculate. More than 90% of patients have no prior genitourinary symptoms or significant factors in their history. The ages range from 14 to 75, with an average age in the late 30′s. It is not uncommon, however, for it to affect men between the ages of 30 and 40. About 90% of men who have had hematospermia will have repeated episodes.
The cause is not specifically known and is poorly understood. Most commonly, it results from nonspecific inflammation of the urethra, prostate and/or seminal vesicles.
In about 50% of patients the cause of hematospermia is not clearly understood or known. Semen originates from multiple organs, including the testicles, epididymis, vas deferens, seminal vesicles, and prostate. Most of the semen comes from the seminal vesicles and prostate and it is probably from these two organs that most hematospermia cases originate.
Infections or inflammation of the organs listed above account for most of the other causes. Cancers are rarely causative and account for a very small percentage of hemospermic diagnoses.
With the introduction of ultrasound-guided prostate biopsies, we are seeing a large number of patients — about a third of the patients who received the test — with hematospermia after the biopsy.
Patients with hematospermia are usually categorized into one of two groups. The primary hematospermia group is where the patient’s only symptom is blood in the ejaculate. This means that there is no blood in the urine (neither visually nor under a microscope). Also, the patient has no symptoms of urinary irritation or infection and the physical exam is completely unremarkable. Patients who have this type of hematospermia with no other findings are essentially found to have no other problem. The condition is “self-limited”, which means it will go away in time without treatment. About 17% of patients will have one episode and no recurrence.
Secondary hematospermia is when the cause of bleeding is known or suspected, such as immediately after a prostate biopsy, in the presence of a urinary or prostate infection, or cancer. Unusual causes include tuberculosis, parasitic infections and any diseases that affect blood clotting such as hemophilia and chronic liver disease. Patients who have hematospermia associated with symptoms of urinary infection or visual and/or microscopic blood in the urine require a complete urologic evaluation.
Most men with hematospermia are in their 30′s and the problem almost always subsides spontaneously, usually within several weeks. Hematospermia may be associated with infection, but is rarely secondary to malignancy. Patients that have persistent hematospermia for longer than three weeks should undergo further urologic evaluation to identify the specific cause.
The physical exam should include a genital and rectal exam, as well as a blood pressure test. Hypertension can be associated with hematospermia. Some urologists recommend transrectal ultrasounds to look for stones and cysts in the prostate, seminal vesicles and ejaculatory ducts. This may also help rule out prostate cancer.
Other urologists recommend cystoscopy because hematospermia can be secondary to urethral and prostatic pathology. Overall, hematospermia almost always resolves spontaneously and rarely is associated with significant urinary pathology. In a Japanese study, less than 1% of patients had prostate cancer associated with hematospermia.
Hematospermia can be a very frightening occurrence to any male, but in the end, most of these patients are found to have no abnormalities and require no therapy. Hematospermia is prone to continue on and off, but it is usually self-limited and carries no increased risk of any other disease, nor is the patient felt to be putting his sexual partner at risk. To reiterate; malignant cancers of the testicles and prostate are very rarely associated with hematospermia.
Bottom line-hematospermia is a frightening condition that suggests a mild inflammation of either the prostate gland or seminal vesicles. No treatment or use of medication will result in return of the semen to its normal color. If you have this condition, check with your doctor or your urologist.