Haematospermia

CLINICAL

Haematospermia

Nandu Dantanarayana

Background aematospermia refers to of assessment is to avoid missing the presence of blood in the malignancy, particularly prostate cancer. Haematospermia is an alarming H ejaculate. The epidemiology of Testicular, bladder and urethral cancer symptom for patients. Reassuringly, haematospermia is poorly described very rarely cause haematospermia, and most cases are benign in origin and because the majority of men do not only if advanced.2 self-limiting. Occasionally, however, an witness their semen.1 For men who underlying malignancy is responsible experience haematospermia, it can Approach and must not be missed by the treating provoke significant anxiety. While most A focused history and examination doctor. cases of haematospermia are benign, it is the initial step in the evaluation of Objective may be secondary to a sinister underlying haematospermia. It is important to pathology and require systematic differentiate between haematospermia The aim of this article is to review the evaluation by the general practitioner and pseudo-haematospermia. The latter causes, diagnosis and management (GP).2 A number of patients may require is haematuria or blood originating from of haematospermia in the primary further evaluation by a urologist or other the patient’s partner. If both haematuria care setting. This review will describe specialist, although even among high-risk and haematospermia are present, an approach to haematospermia that populations, malignancy is rare.3 the approach should be as per the general practitioners (GPs) can apply to haematuria pathway (including urine daily practice. Anatomy cytology, computed tomography [CT] Several anatomical structures contribute intravenous pyelogram and cystoscopy).7 Discussion to the ejaculate and any one of these may Assess for the presence of the red There are numerous potential causes be the source of the haematospermia. flags of haematospermia, in particular:8 of haematospermia, the most common Sperm production begins in the testes • patient’s age (>40 years) of which are infection and iatrogenic. and sperm then travel via the epididymis, • recurrent or persistent Specific red flags of haematospermia vas deferens and ejaculatory duct. Fluid haematospermia identified on clinical assessment and from the seminal vesicles, prostate • prostate cancer risk factors (eg basic investigations help to distinguish and Cowper’s glands then mixes with positive family history or African between harmless haematospermia and sperm to form the ejaculate. Finally, heritage) one that will need specialist referral. The the ejaculate leaves via the urethra. For • constitutional symptoms (eg weight management of haematospermia will haematospermia to occur, the patient loss, anorexia, bone pain). depend on the underlying cause. must have an intact ejaculation function.4 It is also important to keep in mind the common aetiologies of haematospermia Aetiology (are there symptoms of urinary tract There is a broad differential for infection or sexually transmissible haematospermia (Box 1).5 Historically, infection [STI]?). Pain on ejaculation the precise cause of haematospermia is highly suggestive of prostatitis or was often not established and therefore ejaculatory tract obstruction (very termed idiopathic. Recently, iatrogenic rare).5 Haematospermia may be simply and infectious aetiologies have been explained by having had a recent reported as the most common causes urological procedure. Other causes of haematospermia.6 The main aim include prolonged sexual intercourse/

masturbation or, alternatively, a period A digital rectal examination (DRE) • magnetic resonance imaging (MRI) or of prolonged abstinence. GPs should should be conducted to palpate for CT for fine pelvic anatomy detail enquire about a history of tuberculosis prostate carcinoma (asymmetrical, • cystoscopy for bladder and urethral or schistosomiasis, the use of hard nodules, non-tender) or prostatitis pathology. anticoagulants, or the presence of a (intensely tender prostate). Finally, a bleeding disorder.1 systems review should be carried out Management Key features on examination include for features of chronic liver disease, The management of haematospermia blood pressure (for severe hypertension) lymphoma or leukaemia. If there remains will depend on the underlying cause. If and temperature (for evidence of infection- any doubt about whether the patient none is found, and the haematospermia related fever).9 A genital examination of has true haematospermia or pseudo- is an isolated event, reassurance is the penis and urethral meatus, testes, haematospermia, ask the patient to all that is required (Figure 1).6 In an epididymis and spermatic cord should be collect sperm into a condom.1 anxious patient, this can be challenging. performed for the presence of masses, Questions regarding the effects of tenderness or superficial lesions.6 Investigations haematospermia on male fertility and the Certain investigations should be risks of cancer are common. Most causes conducted in all patients with of haematospermia will have no effect on Box 1. Aetiology of haematospermia haematospermia, whereas others should fertility;6 however, some rare pathology Infection (in the form of prostatitis, urethritis, be reserved for those with high-risk such as testicular malignancy may epididymo-orchitis): features.10,11 All patients should undergo diminish reproductive capacity. It is also • Bacterial – chlamydia, gonorrhoea, urine microscopy, culture and sensitivity important to note that the vast majority enterococcus, tuberculosis (MCS) for the presence of infection of men with haematospermia who • Viral – human immunodeficiency virus and red blood cells, urine cytology for have been reviewed and investigated (HIV), cytomegalovirus (CMV), herpes evidence of bladder malignancy, and a full by a urologist do not have an underlying simplex virus (HSV) 2 • Other – schistosomiasis blood count and coagulation studies for malignancy. coagulopathy. After clinical assessment, If an infection is suspected or proven, Iatrogenic if an STI is suspected, urine nucleic appropriate antimicrobials should be • Post-transrectal ultrasound (TRUS) biopsy acid amplification test for chlamydia initiated. For empirical treatment of STIs, • Prostate radiotherapy or brachytherapy • Post-vasectomy and gonorrhoea should be performed, we recommend intramuscular ceftriaxone 13 • Post-orchidectomy ideally with a first-pass urine specimen. and oral azithromycin. For mild-to- A prostate-specific antigen (PSA) assay moderate prostatitis or epididymo-orchitis Malignancy • Prostate should be performed in men >40 years related to a urinary tract infection, we • Bladder of age or if DRE is abnormal or significant recommend trimethoprim or amoxycillin • Testicular prostate cancer risk factors are present. with clavulanic acid, both of which have • Urethral If tuberculosis or schistosomiasis is the good prostate penetration.14 If an unusual Trauma suspected cause of haematospermia, infection is found (eg tuberculosis or • Coital trauma perform urine and semen acid-fast bacilli schistosomiasis), referral to an infectious • Perineal trauma and parasites.6 diseases clinic is appropriate. Prolonged abstinence Patients with iatrogenic Guidelines for urology Obstruction haematospermia should have been • Ductal obstruction referral • Cysts of seminal vesicles/Wolffian duct/ The GP should consider each patient with utricle haematospermia individually. Common Box 2. Indications for urology referral • Calculi of seminal vesicles, ejaculatory indications for referral to a urologist are • Men ≥40 years of age duct, prostate, urethra 7, 1 2 listed in Box 2. • Persistent or recurrent haematospermia Systemic disorders On review by the urologist, the patient • Suspicious DRE findings • Hypertension may undergo further investigations such • Abnormal PSA results • Chronic liver disease as:1 • Suspicion of prostate, bladder, testicular • Lymphoma • transrectal ultrasound (TRUS) or urethral malignancy on history, • Leukaemia for prostate or seminal vesicle examination or investigations • Amyloidosis abnormalities • Concurrent haematuria • Bleeding disorders • scrotal ultrasound to assess for • Haematospermia despite treatment for Idiopathic suspected cause testicular abnormalities

908 REPRINTED FROM AFP VOL.44, NO.12, DECEMBER 2015 © The Royal Australian College of General practitioners 2015 HAEMATOSPERMIA CLINICAL

counselled pre-procedure about the risk the treating urologist may perform work-up by both the GP and urologist, of haematospermia. Post-prostate biopsy interventions such as cystic aspiration one option would be to start a 5-alpha haematospermia usually takes or deroofing, or endoscopic removal of reductase inhibitor such as finasteride 20 ejaculations to resolve.7 If malignancy calculi.3 In the rare event of a systemic or dutasteride. This reduces vascular is identified, the treating urologist cause for haematospermia, appropriate endothelial growth factor (VEGF) will arrange further investigations and speciality referral will have to be made. expression and sub-urethral vessel treatment. Finally, if the patient is troubled by microdensity. It is particularly useful in For ductal obstruction and cystic persistent haematospermia without elderly patients with benign prostatic abnormalities of the accessory glands, an identified cause after a diagnostic bleeding; however, patients should be warned that it may take six months before the haematospermia improves.15 For younger men with persistent idiopathic haematospermia, it is reasonable to Haematospermia consider treatment with one month of doxycycline. Key points Focused history and examination • Haematospermia is an anxiety- provoking symptom in men that may be encountered by the GP. • While most haematospermia is benign Basic investigations: and self-limiting, it may occasionally be • Urine MCS and cytology due to an underlying malignancy (such • Full blood count, coagulation studies as prostate cancer) and hence warrants a systematic evaluation. • Red flags of haematospermia identified on clinical assessment and basic Red flags of haematospermia Nil concerning investigations help distinguish between or features of malignancy on features of harmless haematospermia and that examination/basic investigations malignancy which will need specialist referral. These include patient’s age (≥40 years), recurrent or persistent haematospermia, prostate cancer risk factors (eg positive PSA testing Other specific investigations to consider: family history or African heritage), or • Urine STI testing constitutional symptoms such as weight • TB or schistosomiasis urine testing loss, anorexia, bone pain. • Management of haematospermia will Urology referral and possible: depend on the underlying cause. If • TRUS ± biopsy none is found and the haematospermia Treat No underlying • CT/MRI is an isolated event, reassurance is all • Cystoscopy underlying cause found and no red flags that is required. • Scrotal ultrasound cause if found Author Nandu Dantanarayana MBBS (Hons), MS, Department of Surgery, St Vincent’s Hospital, Darlinghurst, NSW. [email protected] Reassure Competing interests: None. patient Provenance and peer review: Not commissioned, externally peer reviewed.

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