Hematospermia, the presence of grossly bloody or blood-tinged penile (seminal) ejaculate, is an uncommon condition. While it is usually alarming to patients, the cause is almost always benign. Only a few case series have been published, nearly all of which are from urology specialty practices.
Because of the paucity of research literature, there is little evidence on which clinicians can base their evaluation of patients with hematospermia. Searching for the rare causes that have been identified in case reports is not likely to be productive , and the relative frequencies of causes reported in case series from urology specialty practices may not apply to primary care practice. The most important lesson from the literature is that hematospermia is almost never a sign of cancer in younger patients.
The most common cause of hematospermia is prostate biopsy. Hematospermia occurs in more than 80 percent of men undergoing prostate biopsy and lasts for an average of three to four weeks [2,3]. Hematospermia is also common after radiation treatment for prostate cancer, both external beam radiation and brachytherapy. In addition, vasectomy can cause hematospermia for a week or more. Because the cause of hematospermia is obvious in these instances, the remainder of this review will focus on other causes of hematospermia.
A variety of conditions other than prostate biopsy have been reported in patients with hematospermia (table 1) [4-43]. They include benign and malignant disorders of the prostate gland, seminal vesicles, spermatic cord, and ejaculatory duct system; urogenital infections including sexually transmitted infections (eg, chlamydia, herpes simplex virus, gonorrhea, trichomonas); metastatic cancers; vascular malformations; congenital and drug-induced bleeding disorders; and even frequent daily ejaculation over a period of several weeks. However, it is often impossible to know with certainty whether these conditions are the cause of hematospermia. The cause is idiopathic in a substantial proportion of patients, and the condition frequently resolves spontaneously.
It is also difficult to know the true relative frequency of the causes listed in Table 1 because of publication bias that tends to favor reporting of new or unusual causes of hematospermia. In addition, as noted previously, there are no data on the relative prevalence of the causes of hematospermia among patients seen in primary care practice.