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Review Article Review Article Review Article Review Article Review Article Indexed Publications The sanguineous sperm (hemospermia)— current appraisal and review Iqbal Singh Division of Urology, Department of Surgery, University College of Medical Sciences (University of Delhi) & G.T.B Hospital, F-14 South Extension Part-2, New Delhi-110049, India For correspondence: Iqbal Singh, Division of Urology, Department of Surgery, University College of Medical Sciences (University of Delhi) & G.T.B Hospital, F-14 South Extension Part-2, New Delhi-110049, India. E-mail: [email protected] ABSTRACT Aims: Hemospermia is an infrequently discussed urological problem. Most health care providers including general surgeons and physicians are unfamiliar with this disorder, its etiology & management. We undertook the present review to ascertain the magnitude of this problem and to device a working algorithm to help the clinician in approaching a case of hematospermia. The symptoms, differential diagnosis and management have been discussed. Materials and Methods: An Internet search was made over the ‘Pubmed’ for indexed publications in the English literature using the keywords hematospermia; hemospermia and bloody urethral discharge. Results: The search yielded about 75 Review Article Review Article Review Article Review Article Review Article indexed publications. These were reviewed and analyzed to determine the various etiological factors, differential diagnosis and their management. We have suggested a clinical working algorithm and a protocol to deal with cases of hemospermia. Conclusions: Hemospermia is not an uncommon urological disorder. The problem is often idiopathic, transient and self-limiting in more than half the cases. Polysymptomatic persistent hemospermia especially in the elderly may herald a more serious underlying problem that should be investigated thoroughly to rule out malignancy. While not all cases merit an extensive workup, selected cases of recurrent, symptomatic hemospermia associated with other abnormalities may be analyzed in greater detail. The stepwise clinical working algorithm suggested and devised by us on the basis of published cases will assist the treating surgeon/urologist in the evaluation of such suspected cases of hemospermia. Key words: Hematospermia, hemospermia, bloody urethral discharge How to cite this article: Singh I. The sanguineous sperm (hemospermia)—current appraisal and review. Indian J Surg 2005;67:302-7. INTRODUCTION sibility that an individual may be harboring malignan- cy or a serious underlying abnormality. Many surgeons Hemospermia or bloody seminal discharge is & physicians are unfamiliar with this disorder and this an uncommon clinical entity. Though it is con- forms the basis for our current review of hematosper- sidered to be usually due to prostatitis and mia. We have reviewed the various etiological factors, generally runs a benign course resolving spon- and discussed their clinical presentation, differential taneously most of the time, it often invokes diagnosis, diagnostic modalities and the current man- considerable anxiety and is frightening for the agement protocol so as to familiarize the clinician when patient. Though the most common cause is dealing with such cases. infection or inflammation of the prostate, ure- thra and the seminal tract, the older patients Definition and etiology with a persistent hemospermia need to be eval- The international nomenclature of human semen pa- uated. The concern and apprehension in the rameters defines hemospermia (HS) or hematospermia mind of the physician also stems from the pos- as the presence of fresh or altered blood in the ejacu- late derived from pathology of accessory sexual glands, Paper Received: Sepember, 2005. Paper Accepted: December, urethra or the bladder; which is related to emission 2005. Source of Support: Nil. and ejaculation, associated with infertility, hematuria, 302 Indian J Surg | December 2005 | Volume 67 | Issue 6 302 CMYK The sanguineous sperm (hemospermia)–current appraisal and review lower urinary tract obstructive symptoms, vascular series of HS reported by Leary et al[6] comprised 200 abnormalities, ductal obstruction, cysts, neoplasms and men in the 20-74 year age group, with 29% having systemic iatrogenic factors. HS still remains an infre- recurrent HS with a 5-23 year follow up period with quently discussed urological problem that is often rel- 4% developing prostate cancer eight years following egated to the end of most textbooks of urology. Though the initial evaluation. historically HS was thought to be associated with al- tered sexual behavior in the form of overindulgence Clinical features & presentation or prolonged abstinence and inhibition, it is now be- Hemospermia may be mono-symptomatic and prima- lieved to be intermittent, benign and self-limiting in a ry or it may be secondary and present as a poly-symp- majority.[1] According to Perez JR et al even a protract- tomatic disorder in association with other symptoms ed phase of daily ejaculations via masturbation may depending on the underlying etiology. Other diverse cause hematospermia, probably owing to stress of the associated symptoms include pelvic/perineal pain, or- vasculature of the ejaculatory system.[2] The overall lack gasmalgia (pain at the time of orgasm),[7] persistent of awareness and concern by the urologist/clinician dysuria, hematuria, urinary tract infection and infer- stems from a common notion that this is generally a tility (ejaculatory duct obstruction/azoospermia / oli- benign self-limiting problem,[3] though this may not gozoospermia).[8] One must also inquire in to the his- be always correct. It is important that the urologist tory whether HS is acute or chronic and whether it is approach such patients with adequate concern and is mono or polysymptomatic. A history of post ejacula- aware of the underlying conditions, especially malig- tory persistent painless hematuria is strongly sugges- nancy. [Table 1] shows a tabulated list of etiological tive of prostatic/urethral polyps.[9,10] History of perine- factors associated with HS. These may be congenital, al/pelvic pain/discomfort should lead one to the sus- inflammatory, neoplastic, or related to iatrogenic trau- picion of SV/ED cysts/calculi associated infection. His- ma. The commonest cause of HS is idiopathic in more tory of HS associated with infertility, painful ejacula- than 70% of the cases.[4] About 0.5% of patients with tion, and perineal, testicular or scrotal pain should be cancer prostate may present with HS as a sentinel carefully evaluated for possible ejaculatory duct ob- symptom.[3] Iatrogenic trauma leading to HS is most struction (EDO).[11] The blood pressure should be re- commonly seen with transrectal ultrasound guided corded in all cases to rule out hypertension as a cause prostate biopsy and according to one recent large study of hemospermia (at least according to one study hy- of 5957 biopsies performed in 4303 clinically healthy pertension was detected in 7.3 % of the patients pre- men over a ten year period HS occurred as minor com- senting with hemospermia).[12] Massive hemospermia plication in 36.3% of the subjects.[5] [Table 2] depicts a or post ejaculatory gross hemospermia is rarely encoun- summary of reported series and case reports of hemat- tered, the most likely causes include abnormal post ospermia showing their salient features, etiological, urethral vessels or posterior urethral or prostatic api- diagnostic factors and their outcome. One of largest cal varicosities, which may also lead to hematuria, passage of clots and urinary retention. Table 1: Simplified classification of the salient etiological factors leading to hemospermia Diagnosis The initial approach to a patient with HS should in- Congenital Prostatic urethral or adenomatous polyps, papillary prostatic urethral adenomas, clude a detailed history and clinical evaluation includ- hemangiomas, telengiectasia, vascular ing a digital rectal evaluation (DRE). DRE may help in abnormalities, mullerian duct (utricle) cysts, and detection of palpable SV cysts and prostate abnormal- seminal vesicle cysts. (Children and pre-pubertal) ities. It is important to be aware at this stage whether the HS is primary or secondary. Mono-symptomatic Inflammatory Urethroprostatitis or epididymo-orchitis; seminal vesiculitis; calculi of the SV & ED apparatus, or primary HS is more common, often transient, idio- chronic prostatitis, chronic nonbacterial pathic in origin and is generally not associated with prostatitis (chlamydia trachomatis), viral urethral significant urological disease.[12,13] Never the less when- condylomas, SV amyloidosis, malakoplakia of ever a man over forty years presents with hemosper- prostate and SV,genitourinary tuberculosis & mia, prostate cancer screening should be vigilantly schistosomiasis (adolescents) performed since hemospermia may be associated with [3] Neoplastic Cancer and sarcoma of prostate, cancer seminal a higher risk of prostate cancer. A careful seminal vesicle, SV adenomyosis, testicular tumors, cytology/seminogram should be done to differentiate metastasis to seminal vesicles (elderly) clear HS from hemo-pyospermia in order to ascertain Iatrogenic Post ESWLTM lower ureteric calculi, post prostate the underlying pathology.[14,15] The next step should biopsy, post HIFU/TURP, post prostate brachytherapy, post vasectomy. be to perform urine cytology, in case clusters of co- lumnar epithelial cells are found one must consider Medical Hypertension benign prostatic epithelial polyps in the differential SV/ED: Seminal vesicles, ejaculatory duct;
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