Should every patient with hematospermia be investigated? A critical review

Hematospermia or hemospermia is defined as the presence of blood in ejaculate. It often invokes considerable anxiety and is frightening for the patient. Mostly, it is due to infectious causes and regarded as a benign and self–limiting condition particularly in younger patients. Patients above 40 years of age and those with high risk factors require thorough evaluation. Detailed examination is mandatory, and should include: blood pressure measurement and abdominal palpation to identify hepatosplenomegaly or renal enlargement. Genital examination must also be performed to assess for the presence of testicular lumps and urethral discharge, as well as a rectal examination to assess the prostate. Further investigations include cystoscopy, transrectal ultrasound, and prostate biopsy. Diagnosing prostatic pathologies is made easier by performing transrectal ultrasound. It is useful in diagnosing calculi, cysts, prostatic varices, and inflammatory changes, as well as therapeutic in certain cases where cyst or abscess is drained and is found to be the cause of hematospermia. Complex investigations depend on history and examination. A role of MRI is emerging to rule out rare causes of hematospermia. Evidence based evaluation of hematospermia is not only useful in definitive diagnosis, but it can also be cost effective. Therefore, we suggest that patients with high risk factors should be investigated thoroughly. However, younger patients with one episode can be monitored closely and investigated only if deemed necessary.