Jaffal et al (2020): Hematospermia: Causes and Evaluation Nov 2020 Vol. 23 Issue 18

Hematospermia: Causes and Evaluation (A local study)

Waleed Nassar Jaffal1, Duraid Taha Abdulkareem2, Ehab Jasim Mohammad3

1Ass. Professor, FICMS, MBChB, Consultant urologist, Head of Department of Surgery, College of Medicine, ‎University of Anbar, Anbar, Iraq. 2Lecturer of , FIBMS, FABHS, M.B.CH.B. University of Anbar, college of medicine,Iraq

3Professor, FEBU, ,FICMS, MBChB, Consultant Urologist, Head of Department of Surgery, College of Medicine, Ibn Sina University of Medical and Pharmaceutical Sciences, Baghdad, Iraq

*Corresponding author: EhabJasim Mohammad ([email protected]) Abstract: Objectives: To assess the possible causes of hematospermia.Patients and methods: From October 2013 to October 2019, 169 patients presenting with hematospermia in Al Ramadi teaching hospital and private urologist clinic were included in this observational prospective study. The patients were divided into 2 groups according to the age; group A for those who are younger than 40 years and group B for those who are 40 years and older. Complete physical examination and digital rectal examination (DRE) done for every patient, all patients were evaluated by urinalysis, urine culture, complete blood count, serum uric acid measurement, abdominal and /or transrectal ultrasonography, prostatic specific antigen (PSA) and seminal fluid analysis, in addition to urine cytology, polymerase chain reaction (PCR) for urinary , excretory urography, CT scan, MRI, prostatic biopsy and cystoscopy in selected cases.Result:The mean age of patient was 55+10.5 sd ranging from 25 to 75 years. The identified causes in group A are sexually transmitted diseases in 30 patients, in 17 patients, sever hypertension in 10 cases, hyperuricemia in 5 cases, vigorous sexual intercourse in 5 cases, prostatic calculi in 5 case, seminal vesicle calculi in 2 cases, bleeding tendency in one case, urinary tuberculosis in one case and no identifiable causes in the remaining 13 patients. The identified causes in group B are benign prostatic hyperplasia in 32 cases, sever hypertension in 15 cases, active urinary tract infection in 8 cases, prostatic calculi in 6 cases, prostatic cancer in 4 cases, bleeding tendency in 3 cases and no identifiable causes in the remaining 13.Conclusion: The causes of hematospermia are mostly benign as occurrence of serious pathology was rare but patients with alarming features as older age, persistent hematospermia or recurrent hematospermia should have thorough assessment to identify curable diseases and to rule out malignancy.

Key word: hematospermia, seminal fluid, prostatic cancer

How to cite this article: Jaffal WN, Abdulkareem DT, Mohammed EJ (2020): Hematospermia: Causes and evaluation (A local study), Ann Trop Med & Public Health; 23(S18): SP231827. DOI: http://doi.org/10.36295/ASRO.2020.231827

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.231827

Jaffal et al (2020): Hematospermia: Causes and Evaluation Nov 2020 Vol. 23 Issue 18

Introduction

Hematospermia is the presence of blood in the ejaculated human seminal fluid. Despite being a usually an alarming sign and cause fear and big concern to the patient, the causes are commonly benign. Hematospermia is mostly never a sign of malignancy in younger patients. (1,2)The color of ejaculate after the occurrence of bleeding event in hematospermia depends on the time since bleeding. Light red to brownish color means fresh blood, but if some time has elapsed after the occurrence of bleeding, the color will be darker and even dark brown or black blood clots may be seen. Hematospermia is mostly painless and noticed incidentally by the patient or his partner.(3)Among the common causes of hematospermia are transrectal prostatic biopsy, radiotherapy for cancer of the and bilateral vasectomies but in these cases, the cause is known to the patient and don't make any concern to the patient.(4)Therefore, in this study we will exclude these causes and concentrate on other unobvious causes to the patient and the physician and these causes make concern to the patients. The causes are often classified into different pathophysiological mechanisms. Mostly they are iatrogenic, inflammatory and infective in origin. The differential diagnosis of hematospermia may include the following causes; inflammatory and infectivepathologies of the prostate or , hypertension, calculi of the prostate or seminal vesicles, tuberculosis of the prostate, seminal vesicles, vas deferens or the testes, bleeding tendencies, , cancer of the seminal vesicles, prostatic veins varices, hyperuricemia and trauma.(5-10)The standard and the ideal investigation for haematospermia is unknown. There is great concern regarding the association of hematospermia with pathology especially prostatic cancer and there is little evidence based literature regarding this association.(11)In most patients hematospermia is a benign and self-limiting symptom, but some patients who are suffering from recurrent or persistent hematospermia may have more serious underlying organic pathological causes, and further evaluation may be indicated to get rid of their great anxiety, fear, stress, and concern.(12)

Objectives: To assess the possible causes of hematospermia

Patients and methods: from October 2013 to October 2019, 169 patients presenting with hematospermia in Al Ramadi teaching hospital and private urologist clinic were included in this observational prospective study. The patients divided into 2 groups according to the age; group A for those who are younger than 40 years and group B for those who are40 years and older. Patients with diagnosed prostatic cancer, patients undergoing prostatic biopsy were excluded from this study. For all patients: age, marital status, duration of hematospermia was recorded in addition to detailed and thorough medical and surgical history was obtained. Complete physical examination and digital rectal examination (DRE) done for every patient, all patients were evaluated by urinalysis, urine culture, complete blood count, serum uric acid measurement, abdominal and/or transrectal ultrasonography, prostatic specific antigen (PSA) and seminal fluid analysis, in addition to urine cytology, PCR for urinary tuberculosis, excretory urography, CT scan, MRI, prostatic biopsy and cystoscopy in selected cases. Informed consent was obtained from each patient and the study approved by the ethical committee at the collegeof medicine.

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.231827

Jaffal et al (2020): Hematospermia: Causes and Evaluation Nov 2020 Vol. 23 Issue 18

Result:

The mean age of patient was 55+ 10.5 SD ranging from 25 to 75 years. The number of patients who are younger than 40 years are 88 patients (group A) and the number of patients who are 40 years and older was 81 patients (group B).

The identified causes in group Aare sexually transmitted diseases in 30 patients, prostatitis in 17 patients, sever hypertension in 10 cases, hyperuricemia in 5 cases, vigorous sexual intercourse in 5 cases, prostatic calculi in 5 case, seminal vesicle calculi in 2 cases, bleeding tendency in one case, urinary tuberculosis in one case and no identifiable causes in the remaining 12 patients. Table 1

The identified causes in group B are benign prostatic hyperplasia in 32 cases, sever hypertension in 15 cases, active urinary tract infection in 8 cases, prostatic calculi in 6 cases, prostatic cancer in 4 cases, bleeding tendency in 3 cases and no identifiable causes in the remaining 13 patients. Table 2

In all patients of both groups the causes were benign prostatic hyperplasia in 18.9% of patients, sexually transmitted diseases in 17.8%, sever hypertensionin 14.8%, prostatitis in in 10.1%, Prostatic calculiin 6.5%, active urinary tract infection in 4.7%, hyperuricemiain 2.95%, vigorous sexual intercoursein 2.95%, prostatic cancerin 2.4%, bleeding tendency in 2.4%, seminal vesicle calculi in 1.2%, urinary tuberculosis in 0.6 % and remained unknown in 14.2%. Table 3 and Figure 1

Idiopathic

Table 1: Causes of hematospermia in group A (88 patients)

The cause Number Percentage Sexually transmitted diseases 30 34 Prostatitis 17 19.3 Sever hypertension 10 11.4 Hyperuricemia 5 5.9 Vigorous sexual intercourse 5 5.9 Prostatic calculi 5 5.9 Seminal vesicle calculi 2 2.3 Bleeding tendency 1 1.1 Urinary tuberculosis 1 1.1 Idiopathic 12 13.6

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.231827

Jaffal et al (2020): Hematospermia: Causes and Evaluation Nov 2020 Vol. 23 Issue 18

Table 2: Causes of hematospermia in group B (81 patients)

The cause Number Percentage Benign prostatic hyperplasia 32 39.5 Sever hypertension 15 18.5 Active urinary tract infection 8 9.9 Prostatic calculi 6 7.4 Prostatic cancer 4 4.9 Bleeding tendency 3 3.7 Idiopathic 13 1.6

Table 3:The overall causes in all patients (both groups)

The cause Number Percentage Benign prostatic hyperplasia 32 18.9 Sexually transmitted diseases 30 17.8 Sever hypertension 25 14.8 Prostatitis 17 10.1 Prostatic calculi 11 6.5 Active urinary tract infection 8 4.7 Hyperuricemia 5 2.95 Vigorous sexual intercourse 5 2.95 Prostatic cancer 4 2.4 Bleeding tendency 4 2.4 Seminal vesicle calculi 2 1.2 Urinary tuberculosis 1 0.6 Idiopathic 24 14.2

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.231827

Jaffal et al (2020): Hematospermia: Causes and Evaluation Nov 2020 Vol. 23 Issue 18

Figure 1: The causes of hematospermia in both groups

In summary the major causes of hematospermia in all cases are inflammatory and infective.

Regarding the occurrence and the duration of hematospermia, 56patients have single episode with no recurrence and 32 patients have recurrent or persistent hematospermia in group A and 45patients have single episode and36patientshave recurrent or persistent hematospermia in group B. Table 4

Table 4: The occurrence and duration of hematospermia

Hematospermia Group A (N/%) Group B (N/%) Single episode 56/63.6 32/36.4 Recurrent or persistent 45/55.6 36/44.4 Discussion

Although the occurrence of hematospernia causes great anxiety and psychological upset to the patient, is usually self-limiting disease with no major sequellae.(13)

The occurrence of bleeding from any site in thebody is considered alarming and should be taken seriously but the appearance of blood in the seminal fluid is usually due to benign condition and self- limited and not more than simple investigations and reassurance of the patient may be needed.(14)

The formation of ejaculated fluid comes from secretions of the testes, and some accessory sexual glands which passes within the prostatic urethra receiving its secretion and then ejaculated externally through the membranous, bulbar and penile urethra.(15)so any pathological condition at these sites involved in the secretion and passage of the ejaculate may cause hematospermia.

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.231827

Jaffal et al (2020): Hematospermia: Causes and Evaluation Nov 2020 Vol. 23 Issue 18

Iatrogenic trauma is one of the commonest causes of hematospermia, particularly after transrectal prostatic biopsy to diagnose or exclude prostatic cancer. It has been stated by 2 large observational prospective studies that hematospermia had occurred in more than 80% of patients underwent prostatic biopsies and persist for about 4 weeks.(16-18)

But the trauma is obvious to the patient and the physician and it is out of the scope of our study.

In the present study, the causes of hematospermia in the patients who are younger than 40 years were all benign conditions and no serious cause as malignancy was identified and these results are consistent with those of Zargooshi J, et aland Fuse H et al.(13,14)

In older patients, there may be serious cause underlying the hematosperma as prostatic cancer and other genital tract cancers. In the present study 4 cases of prostate cancers where identified, so this group should be thoroughly investigated to rule out the possible serious causes. One of the cases with prostate cancer was 40 year old at the time of diagnosis but he had history of persistent hematuria for 1 year before diagnosis so this finding may be alarming to make thorough investigation for little pit younger patients, although many authors recommend more thorough assessment for over 40 years patients only where MEDLINE searchfrom 1966 to 2008 constructed a management algorithm and stated that in men who are ≤ 40 year old, the causes of hematospermia are most often inflammatory or infectious in origin and in men who are >40 yearold, the hematospermia may be associated with more serious underlying pathologies.(5)

Cancer of the Prostate constituted 5.7% of the causes of hematospermia in a large study of 300 consecutive patients which was prospective study.(11). But in our study it was the cause in 2.4 % and this difference may be due our higher cut off value of the PSA to recommend prostatic biopsy ( >4.0 ng/dl vs of >3.0 ng/dl)

The aim of investigations used for the diagnosis of the causesof hematospermiais to find a clinically important or curable pathology of hematospermia and to confirm or exclude cancer (19,20).

So any patient with alarming features including older age, persistent hematospermia for more than 6 months or recurrent hematospermia should undergo complete assessment including more sophisticated investigations to rule out malignancy.

For the initial management of hematospermia, the etiology evaluation is the best approach.(6)And when it is possible, the treatment is chosen according to the underlying cause but the use of empirical treatment may be chosen if no clear underlying cause of bleeding has been found.(3,21)

Conclusion

The causes of hematospermia are mostly benign as the occurrence of serious pathology was rare but patients with alarming features as older age, persistent hematospermia or recurrent hematospermia should have thorough assessment to identify curable diseases and to rule out malignancy.

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.231827

Jaffal et al (2020): Hematospermia: Causes and Evaluation Nov 2020 Vol. 23 Issue 18

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Jaffal et al (2020): Hematospermia: Causes and Evaluation Nov 2020 Vol. 23 Issue 18

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