Hematospermia

Incidental

findings in and around the prostate on prostate MRI: a pictorial review. Haematospermia (a) Axial T1W image shows intrinsic T1 hyperintensity within the right seminal vesicle (red arrow). b Axial T2W image shows corresponding T2 hypointensity in this region in keeping with blood products (blue arrow). c Coronal T2W and (d) axial T2W images in a different patient show rounded low T2 signal intensity lesions, in the right seminal vesicle in (c) and bilaterally in (d) but larger in the right seminal vesicle, in keeping with stones (white arrows)

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Hematospermia (less commonly hemospermia) refers to the presence of blood in semen or ejaculatory fluid. It is a symptom that can cause great anxiety in patients despite usually being of benign etiology.

Pathology

Etiology

Benign

urogenital infections including sexually transmitted disease, including orchitis and/or epididymitis, and prostatitis
- commonest cause in patients <40 years of age
- seminal vesiculitis and urethritis rarely
benign prostatic hyperplasia (BPH)
trauma
- scrotal
- pelvic
iatrogenic
- prostate instrumentation
ejaculatory duct/seminal vesicular obstruction
- cysts, calculi
chronic abstinence
systemic
- untreated severe hypertension
- bleeding diatheses
- lymphoma
- leukemia
- chronic infections e.g. tuberculosis, schistosomiasis
- amyloidosis

Malignant

Radiographic features

Although imaging is frequently requested in these patients no cause is identified in most cases.

Scrotal ultrasound is commonly requested imaging test in young patients. However, transrectal ultrasound is likely to be more helpful, particularly in patients with suspected prostate malignancy.

MRI with an endorectal coil can be used for the detailed assessment of the prostate and seminal vesicles. Pelvic angiography has been used to look for vascular anomalies in a patient with persistent hematospermia without any other identifiable cause.

Treatment and prognosis

Most patients are young and have episodic symptoms that require no specific treatment.

Approach to hematospermia

The patient's age and persistence of symptoms guide the workup and subsequent treatment for hematospermia. The American College of Radiology has developed guidelines on the investigation of hematospermia to help ensure appropriate use of imaging.

Men <40 years with episodic or transient symptoms and no signs of disease