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Haematospermia Glos Care Pathway Overview

This pathway has been designed to clarify the management of Haematospermia in Gloucestershire.

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Presentation with visible presence of blood in the semen. The blood may appear bright red (bleeding has occurred recently) or red/brown (old).

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.

In 30-70% of the cases there is no association with any significant pathology.

(Weidner W, Jantos C, Schumacher F, et al; Recurrent haemospermia--underlying urogenital anomalies and efficacy of imaging procedures. Br J Urol. 1991 Mar;67(3):317-23.)

Red Flags
Differential Diagnosis
  • Infection (UTI/STI/prostatitis/epididymo-orchitis)
  • Trauma (iatrogenic following urinary tract instrumentation/prostate biopsy, sexual intercourse)
  • Malignancy (prostate, urethra, bladder, testes, rarely seminal vesicles)
  • Tuberculosis of the Genitourinary System

  • Hypertension
  • Calculi of the prostate or seminal vesicles
  • Bleeding disorders
  • Blunt abdominal trauma
Initial Primary Care Assessment

Three factors dictate the extent of the evaluation and treatment include:

  1. patient's age
  2. the duration and recurrence of the hematospermia
  3. the presence of any associated hematuria.

Most malignancies associated with hematospermia occur in patients older than 40 years. Recurrent haematospermia warrants more aggressive intervention to identify an etiologic factor.

  • The number of episodes of haematospermia; 
    • 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;
    • 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.
    • Perineal or suprapubic pain associated with symptoms of a urinary tract infection may indicate acute or chronic prostatitis.
    • Painless haematuria may indicate an underlying urological cancer.
  • Risk factors for, and symptoms of, sexually transmitted infection;
    • Dysuria associated with urethral discharge may indicate a sexually transmitted infection.
  • Symptoms of benign prostatic hypertrophy or prostate cancer;
    • These include hesitancy, frequency, or dribbling.
  • Symptoms of disorders causing an acquired bleeding disorder;
    • These include liver failure, kidney failure, and haematological cancers.

  • 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.
  • 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 microscopy culture and sensitivity 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.
Initial Primary Care Management

No identifiable cause

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.

Identifiable cause

If the haematospermia is secondary to:

  • A urinary tract infection — treat with antibiotics.
  • Suspected prostate cancer — refer the man or boy to a urologist via the 2ww Pathway
  • Suspected benign prostatic hypertrophy
  • Trauma or instrumentation (such as prostatic biopsy) — reassure him that symptoms normally settle within 3–4 weeks.
  • Suspected sexually transmitted infection – see the Sexually Transmitted Infection pages
  • Treat hypertension
When to Refer

No identifiable cause

Refer to a urologist for further assessment:

  • Over 40 years with multiple episodes and no identifiable cause
  • More than 10 episodes of haematospermia in 1 year
  • Recurrent episodes despite treatment of the suspected underlying cause in primary care

Identifiable cause

  • Suspected prostate/testicular cancer — refer via the 2ww Pathway
  • An acquired bleeding disorder (secondary to suspected haematological cancer, or liver or kidney failure) — refer for further assessment to the appropriate specialist.
  • Suspected prostatitis – refer to guidelines
  • Treat hypertension
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