Clinical Topic A-Z Clinical Speciality

Haematospermia

Haematospermia
D051516Hemospermia
D005832Genital Diseases, Male
Kidney disease and urologyMen's healthSexual health
2010-06-14Last revised in June 2010

Haematospermia - Summary

Haematospermia is the visible presence of blood in the semen. The blood appears bright red when bleeding has occurred recently and red/brown when it is old.

In men younger than 40 years of age, haematospermia is usually caused by a benign disorder such as vesiculitis, seminal vesicle calculi, seminal vesicle dilatation, and seminal vesicle cysts. Serious causes are uncommon in this age group and include sexually transmitted infections, carcinoma of the testes or seminal vesicles, severe hypertension, and coagulation disorders.

In men 40 years and older, a serious underlying cause is more likely. The most common serious underlying causes include prostate cancer, benign prostatic hyperplasia, and prostatitis.

Investigations in men younger than 40 years of age include:

A mid-stream urine sample for analysis and culture.

Other investigations guided by clinical findings e.g. tests for a sexually transmitted infection (for men at risk), full blood count, coagulation screen, renal and liver function tests, and scrotal ultrasound (if there is a testicular swelling).

Management in men younger than 40 years includes:

Management of an underlying cause if identified.

If an underlying cause cannot be identified, reassurance that a serious underlying cause is very unlikely and that men under 40 years usually experience only one or two self-limiting episodes of haematospermia.

Referral to a urologist if there are more than three episodes of haematospermia or if there is a prolonged episode of haematospermia (that lasts longer than a month).

In men 40 years and older, referral to a urologist for further assessment is recommended after one episode of haematospermia (unless the man has had a recent prostatic biopsy).

Have I got the right topic?

144months3060monthsMale

This CKS topic covers the management of men and boys with haematospermia of any cause.

There are separate CKS topics on managing conditions that can cause haematuria, including Gonorrhoea, Herpes simplex - genital, LUTS in men, age-related (prostatism), Prostatitis - acute, Prostatitis - chronic, Trichomoniasis, Urethritis - male, Urinary tract infection - children, Urinary tract infection (lower) - men, and Urological cancer - suspected.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.

How up-to-date is this topic?

How up-to-date is this topic?

Changes

Last revised in June 2010

January 2011 — minor update to the text to correct a typographical error. Issued in February 2011.

March to June 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 March 2010.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2010.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2010.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 March 2010.

Primary evidence

No new randomized controlled trials published in the major journals since 1 March 2010.

New policies

No new national policies or guidelines since 1 March 2010.

New safety alerts

No new safety alerts since 1 March 2010.

Changes in product availability

No changes in product availability since 1 March 2010.

Goals and outcome measures

Goals

To support primary healthcare professionals:

Determine the cause of haematospermia

Manage the cause of haematospermia, when possible

Refer for specialist investigation and management, when appropriate

Background information

Definition

What is it?

Haematospermia is the visible presence of blood in the semen. The blood appears bright red when bleeding has occurred recently and red/brown when it is old [Ahmad and Krishna, 2007].

Prevalence

How common is it?

CKS identified no studies quantifying the incidence of haematospermia in the general population.

Haematospermia is most common in men younger than 40 years of age.

Expert reviews report that haematospermia is most common in men younger than 40 years of age, although the evidence to support this is limited [Ahmad and Krishna, 2007; Torigian and Ramchandani, 2007; Aslam et al, 2009].

In one of the few studies to report the age of men presenting with new-onset haematospermia, 88% of the 74 men were younger than 40 years of age [Jones, 1991].

Causes

What causes it?

Haematospermia is associated with disorders of the structures that produce semen and convey it during ejaculation. These structures include the testes, epididymides, vas deferentia, ejaculatory ducts, seminal vesicles, prostate, Cowper's glands, and urethra.

Men younger than 40 years of age

Most causes of haematospermia are benign. Men in this age group usually present with one or two isolated episodes of haematospermia followed by resolution of symptoms. Causes include vesiculitis, seminal vesicle calculi, seminal vesicle dilatation, and benign seminal vesicle cysts.

Serious causes for haematospermia are uncommon, but are considered more likely in men with recurrent and prolonged episodes of haematospermia. Serious causes include:

Sexually transmitted infections, including herpes simplex virus, chlamydia, gonorrhoea, trichomoniasis, and genital warts in the urethra.

Carcinoma of the testes or seminal vesicles.

Severe hypertension.

Coagulation disorders.

Men of 40 years of age or older

A significant proportion have a serious cause for haematospermia, although the benign causes found in younger men are still common.

The most common serious causes for haematospermia include prostate cancer and bleeding following prostate biopsy, benign prostatic hyperplasia, and prostatitis.

Uncommon serious causes for haematospermia in men older than 40 years of age include:

Sexually transmitted infections, including herpes simplex virus, chlamydia, gonorrhoea, trichomoniasis, and genital warts in the urethra.

Carcinoma of the testes or seminal vesicles.

Severe hypertension.

Coagulation disorders.

[Torigian and Ramchandani, 2007]

Assessment

Assessment of haematospermia

Assessment

How do I determine the cause of haematospermia?

Ask about:

Age. Men older than 40 years of age with haematospermia are at increased risk of a serious cause for haematospermia, such as prostate cancer or prostatitis.

The number of episodes of haematospermia he has had. Prolonged recurrent episodes are thought to increase the risk of a serious underlying cause for haematospermia.

Recent instrumentation or trauma to the genitalia.

Known bleeding disorders, such as haemophilia or von Willebrand's disease.

Symptoms of urological infection or cancer.

Dysuria, urgency, or frequency, with or without haematuria, may indicate a urinary tract infection. For further information, see the CKS topics on Urinary tract infection (lower) - men and Urinary tract infection - children.

Perineal or suprapubic pain associated with symptoms of a urinary tract infection may indicate acute or chronic prostatitis. For further information, see the CKS topics on Prostatitis - acute and Prostatitis - chronic.

Painless haematuria may indicate an underlying urological cancer. For further information, see the CKS topic on Urological cancer - suspected.

Risk factors for, and symptoms of, sexually transmitted infection. Dysuria associated with urethral discharge may indicate a sexually transmitted infection. For further information, see the CKS topics on Urethritis - male, Gonorrhoea, Trichomoniasis, and Herpes simplex - genital.

Symptoms of benign prostatic hypertrophy or prostate cancer. These include hesitancy, frequency, or dribbling. For further information, see the CKS topic on LUTS in men, age-related (prostatism).

Symptoms of disorders causing an acquired bleeding disorder. These include liver failure, kidney failure, and haematological cancers.

Examine:

Blood pressure for uncontrolled hypertension.

For signs of anaemia and bruising associated with an acquired bleeding disorder.

The penis and the urethral meatus for signs of genital warts, or unreported injury.

The testes for signs of cancer. For further information, see the CKS topic on Scrotal swellings.

The prostate for signs of benign prostatic hyperplasia or cancer.

The abdomen for abnormalities of the kidneys, liver, or spleen that could indicate an acquired bleeding disorder.

Send a mid-stream urine sample for analysis and culture in all men and boys.

Consider other investigations guided by clinical findings:

Investigations for a sexually transmitted infection (in men with symptoms or who are at risk).

A full blood count, coagulation screen, and renal and liver function tests.

Prostate specific antigen (PSA) level if prostate cancer is suspected.

Scrotal ultrasound if there is testicular swelling.

Basis for recommendation

Basis for recommendation

Experts recommend assessing all people for serious conditions thought to cause haematospermia [Narouz and Wallace, 2002; Papp et al, 2003; Ahmad and Krishna, 2007; Magoha and Magoha, 2007; Aslam et al, 2009; Stefanovic et al, 2009]. Expert review articles on secondary care management commonly recommend arranging a wide range of blood tests and screening for sexually transmitted infections in all men. However, this was not supported by CKS expert reviewers for men presenting in primary care.

Management

Management

Scenario : Management : covers management following primary care assessment of the cause of haematospermia.

Scenario : Management

Scenario : Management of haematospermia

144months3060monthsMale

No identifiable cause

How should I manage a man with no identifiable cause for haematospermia?

For men younger than 40 years of age who have had no more than three episodes of haematospermia within one month:

Reassure that a serious cause is extremely unlikely.

Advise the man or boy to return if more than three episodes of haematospermia occur or episodes of haematospermia continue for more than one month.

For men of 40 years of age or older, those who have experienced more than three episodes of haematospermia, and those experiencing episodes of haematospermia for more than one month, refer to a urologist for further assessment.

Basis for recommendation

Basis for recommendation

Referral criteria are based on expert opinion of the risk of a serious cause for haematospermia [Ahmad and Krishna, 2007; Torigian and Ramchandani, 2007; Szlauer and Jungwirth, 2008; Leocadio and Stein, 2009; Stefanovic et al, 2009].

The association between persistent haematospermia and serious pathology is based on expert opinion. CKS identified no trials that looked for this association.

Expert opinion is supported by limited evidence that there is probably an increased risk of prostate cancer in men of 40 years of age and older with haematospermia.

There is further limited evidence that the risk of a serious cause for haematospermia is extremely low in men younger than 40 years of age.

Identifiable cause

How should I manage a man with an identifiable cause for haematospermia?

If the haematospermia is secondary to:

A urinary tract infection — treat with antibiotics. For further information, see the CKS topic on Urinary tract infection (lower) - men and Urinary tract infection - children.

Suspected prostate cancer — refer the man or boy to a urologist. For further information, see the CKS topic on Urological cancer - suspected.

Suspected testicular cancer — see the CKS topic on Scrotal swellings.

Suspected benign prostatic hypertrophy — see the CKS topic on LUTS in men, age-related (prostatism).

Suspected prostatitis — see the CKS topics on Prostatitis - acute and Prostatitis - chronic.

Trauma or instrumentation (such as prostatic biopsy) — reassure him that symptoms normally settle within 3–4 weeks.

Suspected sexually transmitted infection — refer the man or boy to a service specializing in sexual health for further investigation and management. For further information, see the CKS topics on Urethritis - male, Gonorrhoea, Trichomoniasis, and Herpes simplex - genital.

An acquired bleeding disorder (secondary to suspected haematological cancer, or liver or kidney failure) — refer for further assessment to the appropriate specialist.

Basis for recommendation

Basis for recommendation

Haematospermia following instrumentation

The recommendation to reassure men with haematospermia following prostatic biopsy is based on an observational study of the incidence and duration of haematospermia following transrectal ultrasound-guided prostate biopsy [Manoharan et al, 2007].

Following transrectal ultrasound-guided prostate biopsy, 63 men were instructed to ejaculate at least once weekly and record any episodes of haematospermia.

A total of 84% of men had at least one episode of haematospermia.

The mean duration of symptoms was 3.5 weeks.

Haematospermia secondary to causes other than instrumentation

Management recommendations for other causes of haematospermia, and the basis for these recommendations, are located within the appropriate CKS topic.

Evidence

Evidence

Supporting evidence

Evidence on the causes of haematospermia by age is summarized in this section to support the recommendations on the assessment and management of haematospermia.

Risk of serious cause

Evidence on the risk of a serious cause for haematospermia by age

Limited evidence suggests that there is probably an increased risk of prostate cancer in men of 40 years of age and older with haematospermia. In men younger than 40 years of age, there is evidence that the risk of a serious cause is extremely low.

Risk of prostate cancer in men with haematospermia

Screening for prostate cancer was done in 26,000 men older than 50 years of age, or older than 40 years of age with a family history of prostate cancer [Han et al, 2004].

Prostate cancer was identified in 6.5% of all the men screened.

Prostate cancer was identified in 14% of 139 men who also reported having haematospermia.

The increased risk of prostate cancer in men with haematospermia did not quite reach statistical significance (odds ratio 1.73, p = 0.054).

An expert review identified 11 published case series of men with haematospermia [Ahmad and Krishna, 2007].

Of 931 men with haematospermia, 33 were found to have underlying cancer.

Prostate cancer was identified in 25 men.

Risk of cancer in men younger than 40 years of age with haematospermia

An expert review identified 11 published case series of men with haematospermia [Ahmad and Krishna, 2007].

Of 931 men with haematospermia, 33 were found to have underlying cancer.

No cancers were identified in men younger than 40 years of age.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of haematospermia, with additional searches for evidence in the following areas:

Risk of sexually transmitted disease

Search dates

January 1990 – March 2008

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.

exp Hemospermia/, haemospermia.tw, hematospermia.tw, haematospermia.tw, exp Genital Diseases, Male/

exp Sexually Transmitted Diseases/, STI.tw., STD.tw., sexually transmitted infection.tw., sexually transmitted disease.tw.

Table 1 . Key to search terms.
Search commands Explanation
/ indicates a MeSh subject heading with all subheadings selected
.tw indicates a search for a term in the title or abstract
exp indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$ indicates that the search term was truncated (e.g. wart$ searches for wart and warts)
Sources of guidelines

National Institute for Health and Care Excellence (NICE)

Scottish Intercollegiate Guidelines Network (SIGN)

National Guidelines Clearinghouse

New Zealand Guidelines Group

British Columbia Medical Association

Canadian Medical Association

Institute for Clinical Systems Improvement

Guidelines International Network

National Library of Guidelines

National Health and Medical Research Council (Australia)

Alberta Medical Association

University of Michigan Medical School

Michigan Quality Improvement Consortium

Royal College of Nursing

Singapore Ministry of Health

Health Protection Agency

National Resource for Infection Control

CREST

World Health Organization

NHS Scotland National Patient Pathways

Agency for Healthcare Research and Quality

TRIP database

Patient UK Guideline links

UK Ambulance Service Clinical Practice Guidelines

RefHELP NHS Lothian Referral Guidelines

Medline (with guideline filter)

Driver and Vehicle Licensing Agency

Sources of systematic reviews and meta-analyses

The Cochrane Library :

Systematic reviews

Protocols

Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)

EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme

The Cochrane Library :

NHS Economic Evaluations

Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health

International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library :

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)

EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Bandolier

Drug & Therapeutics Bulletin

MeReC

NPCi

BMJ Clinical Evidence

DynaMed

TRIP database

Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

Department of Health

Health Management Information Consortium (HMIC)

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

British National Formulary (BNF)

electronic Medicines Compendium (eMC)

European Medicines Agency (EMEA)

LactMed

Medicines and Healthcare products Regulatory Agency (MHRA)

REPROTOX

Scottish Medicines Consortium

Stockley's Drug Interactions

TERIS

TOXBASE

Micromedex

UK Medicines Information

References

Ahmad, I. and Krishna, N.S. (2007) Hemospermia. Journal of Urology 177(5), 1613-1618. [Abstract]

Aslam, M.I., Cheetham, P. and Miller, M.A. (2009) A management algorithm for hematospermia. Nature Reviews. Urology 6(7), 398-402. [Abstract]

Han, M., Brannigan, R.E., Antenor, J.A. et al. (2004) Association of hemospermia with prostate cancer. Journal of Urology 172(6 Pt 1), 2189-2192. [Abstract]

Jones, D.J. (1991) Haemospermia: a prospective study. British Journal of Urology 67(1), 88-90. [Abstract]

Leocadio, D.E. and Stein, B.S. (2009) Hematospermia: etiological and management considerations. International Urology and Nephrology 41(1), 77-83. [Abstract]

Magoha, G.A. and Magoha, O.B. (2007) Aetiology, diagnosis and management of haemospermia: a review. East African Medical Journal 84(12), 589-594. [Abstract] [Free Full-text]

Manoharan, M., Ayyathurai, R., Nieder, A.M. and Soloway, M.S. (2007) Hemospermia following transrectal ultrasound-guided prostate biopsy: a prospective study. Prostate Cancer & Prostatic Diseases 10(3), 283-287. [Abstract]

Narouz, N. and Wallace, D.M. (2002) Haematospermia: in the context of a genitourinary medicine setting. International Journal of STD & AIDS 13(8), 517-521. [Abstract]

Papp, G.K., Kopa, Z., Szabo, F. and Erdei, E. (2003) Aetiology of haemospermia. Andrologia 35(5), 317-320. [Abstract]

Stefanovic, K.B., Gregg, P.C. and Soung, M. (2009) Evaluation and treatment of hematospermia. American Family Physician 80(12), 1421-1427.

Szlauer, R. and Jungwirth, A. (2008) Haematospermia: diagnosis and treatment. Andrologia 40(2), 120-124. [Abstract]

Torigian, D.A. and Ramchandani, P. (2007) Hematospermia: imaging findings. Abdominal Imaging 32(1), 29-49. [Abstract]