International Journal of Impotence Research (2013) 26, 83–86 & 2013 Macmillan Publishers Limited All rights reserved 0955-9930/13 www.nature.com/ijir ORIGINAL ARTICLE Hemospermia: long-term outcome in 165 patients J Zargooshi, S Nourizad, S Vaziri, MR Nikbakht, A Almasi, K Ghadiri, S Bidhendi, H Khazaie, H Motaee, S Malek-Khosravi, N Farshchian, M Rezaei, Z Rahimi, R Khalili, L Yazdaani, K Najafinia and M Hatam Long-term course of hemospermia has not been addressed in the sexual medicine literature. We report our 15 years’ experience. From 1997 to 2012, 165 patients presented with hemospermia. Mean age was 38 years. Mean follow-up was 83 months. Laboratory evaluation and testis and transabdominal ultrasonography was done in all. Since 2008, all sonographies were done by the first author. One patient had urinary tuberculosis, one had bladder tumor and three had benign lesions at verumontanum. One patient had bilateral partial ejaculatory duct obstruction by stones. All six patients had persistent, frequently recurring or high-volume hemospermia. All pathologies were found in young patients. In the remaining 159 patients (96%), empiric treatment was given with a fluoroquinolone (Ciprofloxacin) plus an nonsteroidal anti-inflammatory drug (Celecoxib). In our 15 years of follow-up, no patient later developed life-threatening disease. Diagnostic evaluation of hemospermia is not worthwhile in the absolute majority of cases. Advanced age makes no difference. Only high-risk patients need to be evaluated. The vast majority of cases may be safely and effectively treated with empiric therapy. Almost all patients do well in long term. International Journal of Impotence Research (2013) 26, 83–86; doi:10.1038/ijir.2013.40; published online 5 December 2013 Keywords: genital diseases; hemorrhage; hemospermia; male; semen INTRODUCTION provider of specialized sexual medicine health care and the sole Hemospermia (hematospermia) is the presence of blood in the destination for the referral cases of sexual medicine in the Kermanshah province and the neighboring five provinces of western Iran (Ilam, Loristan, semen. Despite being a source of considerable anxiety in patients, Kurdistan, Khuzestan and Hamadan). From the first day of launching the hemospermia and its long-term clinical course has not been clinic, we have recorded the patients’ full clinical and laboratory data into adequately addressed in the sexual medicine literature. Reported our electronic information storage and retrieval system, the UNESCO’s experience in various countries shows that hemospermia is rarely database management system CDS/ISIS. For the purpose of this article, a associated with any significant urologic pathology. In India,1 among search of the chief complaint field of our electronic data set was done for 35 patients with hemospermia, infection was the most common the keyword hemospermia. After saving the search results, electronic files cause (40%). In Taiwan,2 no prostate cancer was found in 40 of the identified patients were reviewed and relevant information was patients with hemospermia. In Korea,3 again, no prostate cancer extracted and summarized. Based on our database search, from 2 January found in 17 patients with hemospermia. In Italy,4 no malignant 1997 to 15 March 2012, 165 patients presented to us with the chief complaint of hemospermia of 1 day to 2 years duration. During the same disease was demonstrated in 90 patients with hemospermia. In 5 period, we have seen 36 252 patients with urologic complaints. Thus, Japan, too, no malignant lesions were found in the prostate or considering our very large case load, our hemospermia cases are seminal vesicles of 46 patients with hemospermia. In these studies, representative of the rest of the urological community in western Iran. A the patients underwent evaluation with transrectal ultrasound uniform diagnostic, therapeutic and follow-up protocol was used for all (TRUS) and/or endorectal coil magnetic resonance imaging (MRI). patients as follows. History was obtained and physical examination To exclude the possibility of tuberculosis and transitional cell including digital rectal examination was done in all. Kidneys, bladder, carcinoma of the prostatic urethra, it has been recommended to seminal vesicles and prostate were evaluated by transabdominal perform a genital and rectal examination and to request prostate ultrasonography, to rule out genitourinary schistosomiasis, tuberculosis, specific antigen (PSA) testing and urinary cytology. Despite hydatidosis, prostatitis, benign prostate hyperplasia, transitional prostate cancer and obstruction of ejaculatory duct by stones, strictures, polyps, generally being a spontaneously resolving, benign condition, tumors and cysts. By transabdominal sonography, we meant transabdom- hemospermia is being increasingly investigated with expensive 2–5 inal sonography of kidneys, bladder and prostate, not the whole diagnostic technologies such as MRI and TRUS. To our abdominal contents. Testes, too, were evaluated ultrasonographically, to knowledge, based on a review of PubMed, long-term course of rule out epididymitis, orchitis and testis tumors. hemospermia has not been adequately evaluated. Here we report Since 19 July 2008, all sonographies were personally done by the first our experience with 165 hemospermic patients who have been author. Before that time, radiologists performed the sonographies. The visited and followed by the first author during a 15-year period. uniform laboratory evaluation include urinalysis and urine culture, serum PSA, serum markers of testis cancer (alpha feto protein and beta-human chorionic gonadotropin, coagulation parameters, semen analysis, complete MATERIALS AND METHODS blood count and differential, urine cytology to exclude the possibility of The database for this report includes all patients with hemospermia seen in transitional cell carcinoma of the prostate, and urine smear and culture for our outpatient clinic during the past 16 years. The clinic was launched in tuberculosis. PSA and testis tumor markers were evaluated to rule out 1996. The clinic is a general urology clinic. We also have been the main prostate and testis cancer, respectively. The sexually transmitted disease Department of Sexual Medicine, The Rhazes Center for Research in Family Health and Sexual Medicine, and Nosocomial Infections Research Center, Muhammad Zakariya Razi (Rhazes) Boulevard, Kermanshah University of Medical Sciences, Kermanshah, Iran. Correspondence: Dr S Bidhendi, Department of Sexual Medicine, and the Rhazes Center for Research in Family Health and Sexual Medicine, Kermanshah University of Medical Sciences, Muhammad Zakariya Razi (Rhazes) Boulevard, Kermanshah University of Medical Sciences, Kermanshah, Iran. E-mail: [email protected] Received 12 July 2012; revised 4 September 2013; accepted 20 October 2013; published online 5 December 2013 Long-term outcome of hemospermia J Zargooshi et al 84 that is common in this area is gonorrhea. Thus, a urethral smear was spermia was absent in the second visit and never recurred in 149 ordered routinely. Other sexually transmitted diseases were not a concern patients. In the remaining eight, hemospermia was present in at in our cases because we knew the patients’ full medical and sexual history least two visits or its presence was reported to us in the follow-up that was not suggestive of sexually transmitted disease. Thus, we did not calls. In two of these patients, hemospermia occurred only very assess them for other sexually transmitted diseases including chlamydia. If occasionally and responded to the empiric therapy. However, in the laboratory and ultrasonographic evaluations were negative, empiric treatment was given (a fluoroquinolone plus nonsteroidal anti-inflamma- remaining six, hemospermia was persistent, frequently recurring or tory drug). The patients were prescribed a follow-up schedule as follows. high-volume hemospermia. In these six patients, definite etiologies They were asked to present for visit if hemospermia persisted or recurred. were found for hemospermia. One patient had urinary tuberculosis, If completely asymptomatic, they were interviewed regularly (every 6 one had bladder tumor and three had biopsy-proven benign months) by phone, asking about their interim condition. We personally papillary lesions at verumontanum. One patient was diagnosed with called the patients by phone, asking about their interim condition. We bilateral partial ejaculatory duct obstruction by stones. Figure 1 asked: ‘did you have any episode of bloody semen in the intervening time, summarizes the long-term follow-up data. All pathologies were namely after the last visit/call?’ found in young patients (none older than 32 years). If the patients were asymptomatic for 2 consecutive years, then we There was no difference in outcome among patients with more called them yearly. Patients who could not be contacted were deemed lost to follow-up, not cured or failed. than one symptom besides hemospermia, including ejaculatory Considering our clinical and laboratory evaluation of the patients, we are pain or infertility. certain, to a reasonable extent, about other health conditions of the patients. Table 2. Laboratory and sonographic results RESULTS Parameter Mean Standard deviation Median Mean follow-up was 83 months (range 2–171, median 79, s.d. 48). AFP (ng ml–1) 2.41 1.32 2.2 Mean age was 38 years (range 18–76 years, median 36, s.d. 13.3). B-HCG (U l–1) 1.16 0.61 1.3 Age categories by decade, and associated findings including