Haematospermia

 

Haematospermia is the visible presence of blood in the semen. The blood appears bright red (with or without clots) when bleeding has occurred recently and red/brown when it is old.  It can occur as a single episode, or repeatedly over time.  Haematospermia is thought to be most common in men younger than 40 years of age.  Most cases of haematospermia have a benign cause.  In men younger than 40 years of age, the most common cause is infection (urinary tract infection or sexually transmitted infection).  In men of 40 years of age or older, malignancy is a more common cause than in men under 40 years old

.

Assessment

Note the person's age. Men older than 40 years of age with haematospermia are at increased risk of a serious underlying cause

Ask about:

  1. The duration and frequency of haematospermia.  (Prolonged and/or recurrent episodes increase the risk of a serious underlying cause)
  2. The colour of the semen.  (Bright red (with or without clots) indicates fresh bleeding, while older blood may appear brown)
  3. Any associated symptoms.  (Dysuria, frequencyurgency, visible haematuriapain in the abdomen, scrotum, pelvis, or perineum can all indicated a UTI; additional symptoms perineal or suprapubic pain can indicate acute or chronic prostatitis; urethral discharge may indicate an STI; painless haematuria may indicate an underlying urological cancer; whilst urinary hesitancy, frequency, or dribbling may indicate benign prostatic hypertrophy or prostate cancer)

.

Examine the person:

  1. Measure blood pressure for signs of uncontrolled hypertension
  2. Palpate the testes to detect lumps, scrotal tenderness, or swelling
  3. Consider performing a digital rectal examination (DRE) to detect prostatic enlargement, tenderness, fluctuance, firmness, or nodules
  4. Look for signs of easy bruising or bleeding tendencies, such as petechiae and large bruises (greater than 5 cm in diameter) in the absence of trauma
  5. Examine the abdomen for hepatosplenomegaly, which could indicate an underlying haematological, liver, or infectious disease

.

Investigations prior to referral

  1. Send a mid-stream urine sample for culture and analysis in all men and boys
  2. Measure the PSA level in all men aged over 40 years
  3. Consider other investigations guided by clinical findings, including
    1. FBC, coagulation screen, and renal and LFTs
    2. PSA test in men of any age with signs and symptoms, or a family history of prostate cancer
    3. Scrotal ultrasound if there is testicular swelling

.

Exclude Red Flag Symptoms

Exclude the following red flag symptoms:

  • Haematuria
  • Testicular mass
  • Abnormal DRE or
  • Elevated age-specific PSA

.

Management

If the person is under 40 years old, and no underlying cause is identified by initial assessments and investigations:

  1. Reassure them that a single episode is likely to be benign and self-limiting
  2. Reassure them that a serious cause is extremely unlikely
  3. Advise them to return if more than three episodes of haematospermia occur or episodes of haematospermia continue for more than one month

.

If a sexually transmitted infection is suspected, refer the person to a genitourinary medicine (GUM) clinic

If a urinary tract infection is suspected, treat with antibiotics based on the results of culture and sensitivity tests, and according to local prescribing guidelines. See guidance on UTIs in menwomen and children

If the person has hypertension, treat appropriately

If acute or chronic prostatitis is suspected, click here for advice on management

.

When to refer

Urgently refer to an urologist:

  1. Men of 40 years of age or older with episodes of haematospermia with no identifiable cause found in primary care
  2. Men of any age with signs and symptoms suggestive of prostate cancer (such as elevated PSA levelssuspicious findings on digital rectal examination), and men or boys with signs or symptoms suggestive of testicular or urological malignancies

.

Urgently refer to an appropriate specialist if the person has signs and symptoms suggestive of an acquired bleeding disorder, lymphoma or leukaemiatuberculosis, or schistosomiasis

.

Refer to an urologist:

  1. Men who have experienced more than three episodes of haematospermia
  2. Men who have experienced episodes of haematospermia for more than one month
  3. Men and boys where initial investigations have suggested that the underlying cause of haematospermia may be cysts or calculi of the prostate or seminal vesicles
  4. Men and boys who continue to experience haematospermia despite treatment of a suspected underlying cause identified in primary care

.

Patient choice

  1. Reassure the person that most causes of haematospermia have no effect on fertility. The main exception to this is when the underlying cause is certain sexually transmitted infections
  2. Reassure men who have hasd a recent prostate procedure that any associated haematospermia should resolve within three to four weeks

.

Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

Have a question or query?

Get in touch