Haematospermia

🩸 About

• Haematospermia = visible blood in the ejaculate.
• In the UK it is usually benign and self-limiting, especially in younger men.
• It can be distressing—clear, calm reassurance and safety-netting are key.

🔬 Why it happens (pathophysiology)

Semen is produced by the prostate and seminal vesicles and passes through the ejaculatory ducts and urethra. Inflammation, infection, fragile vessels, or minor trauma in any of these structures can leak a small amount of blood into semen. Anticoagulants and high ejaculatory frequency (or prolonged abstinence then vigorous activity) can lower the threshold for bleeding. In men >45 years or with persistent/recurrent episodes, consider structural causes (e.g., seminal vesicle/prostate pathology) and coexisting haematuria.

🧾 Aetiology (think “I3-TAP”)

• Infection/inflammation: prostatitis, epididymo-orchitis, urethritis (incl. STIs).
• Iatrogenic: prostate biopsy, vasectomy, catheter/trauma.
• Increased bleeding tendency: anticoagulants, thrombocytopenia, coagulopathy.
• Tumour (uncommon): prostate, seminal vesicle, urethral lesions (risk ↑ with age).
• Anomalies/obstruction: stones, cysts, ejaculatory duct or SV pathology.
• Physiological/mechanical: vigorous intercourse/masturbation, prolonged abstinence, hypertension spikes.

🧑‍⚕️ Clinical assessment

• Clarify frequency, duration, and volume (streaks vs clots; single vs recurrent).
• Exclude haematuria (ask about blood mixed in urine; do urinalysis) and rectal bleeding.
• Symptoms: LUTS, dysuria, fever, pelvic/perineal pain, urethral discharge, systemic “B” symptoms.
• Medication history: anticoagulants/antiplatelets, supplements (e.g., fish oil), recent procedures.
• Exam: genital & scrotal exam (masses, tenderness), DRE for prostate (tender vs suspicious), BP/temperature.

🧪 Investigations (primary care)

• Urinalysis ± urine culture (exclude UTI/haematuria).
• STI screen (NAAT for chlamydia/gonorrhoea) in younger/at-risk patients.
• FBC & coagulation if heavy/recurrent or on anticoagulants.
• PSA (age-appropriate) if >45 years, abnormal DRE, LUTS, or persistent episodes (avoid testing during acute prostatitis).
• Rarely needed initially: renal/bladder USS, TRUS, cystoscopy (consider if persistent >3 months, abnormal findings, or haematuria).

🚦 Red flags — consider urgent urology

🧰 Management (primary care)

• ✅ Reassure: most cases resolve within a few weeks; abstain or be gentle for 1–2 weeks if temporally related to vigorous activity.
• 🦠 Treat suspected infection: STI-directed therapy (per local guideline) or prostatitis regimen if typical features (avoid PSA in acute prostatitis; check again later).
• 💊 Review/optimise anticoagulants/antiplatelets with the prescriber if heavy/persistent bleeding (risk–benefit discussion; do not stop abruptly).
• 🧂 Supportive: hydration, avoid NSAIDs if bleeding problematic, manage anxiety (clear safety-netting).
• 📮 Refer to urology if: age >45, ≥3 episodes, abnormal PSA/DRE, haematuria, abnormal exam, systemic features, or persistence >3 months.

🧠 Teaching pearls (for juniors)

• PSA can be falsely elevated for several weeks after prostatitis, ejaculation, or DRE; time your test.
• Differentiate haematospermia vs haematuria by asking if blood is present only in semen or also in urine.
• Most urology clinics investigate only if persistent/recurrent or if there are red flags; a single brief episode in a young man rarely needs imaging.

🖼️ Patient-friendly message

💬 “Seeing blood in semen is common and usually harmless. It often settles on its own. We’ll check for infection and any warning signs; if these are absent, reassurance and watchful waiting are appropriate. Come back sooner if you also see blood in the urine, develop pain/fever, or the bleeding persists.”

References

• BMJ Best Practice — Haematospermia
• BAUS (British Association of Urological Surgeons) — Patient information on haematospermia