Oh my G-d, I just ejaculated blood. It’s Hematospermia: Don’t panic

Hematospermia literally means blood in the ejaculate. For men who have experienced it, it can be a shocking situation and a cause for tremendous anxiety. The cause for it is (not universally but) most commonly, benign. Why and how does it happen?

The majority fluid in the ejaculate comes from 2 sources: the prostate and seminal vesicles; they account for 95% of the fluid. The prostate sits below a man’s bladder and surrounds the prostatic urethra. The Seminal vesicles lie above and behind the prostate and join the ampulla of the vas to form the ejaculatory ducts. Those ducts travel through the prostate to empty into the prostatic urethra.

The vasa carry sperm from the testis and epididymis to the ejaculatory ducts. The sperm contribution accounts for almost 5 % of the ejaculate volume. Separately, Cowpers (bulbourethral) glands can also contribute a little fluid.

The true prevalence and incidence of hematospermia is unknown, but a urologist typically sees at least a few unnerved individuals a year with this complaint. Some patients have only one episode. However, once there is blood in the seminal vesicle, the hematospermia can recur over 2 weeks to 2 months without significance.

The typical approach at first presentation is for the physician to obtain a history including history relevant to risk for urinary infection and or sexually transmitted disease. A physical examination including a prostate examination (which also includes examination of the seminal vesicles) is performed and a urine analysis is performed. In cases of persistent or recurrent hematospermia, the physician may order imaging studies such as prostate ultrasound or pelvic MRI. Pelvic MRI currently offers the most sensitive and specific means of looking for any anatomic abnormality in the pelvis.

The cause for hematospermia is idiopathic (happens by itself) in the majority of cases. Less commonly, infection may be involved. Some anatomic abnormalities such as a cyst in the prostate or ejaculatory duct can be associated with the condition. Prostate calculi or stones have also (rarely) been seen in association. Surgical procedures such as prostate biopsy or prostate resection (TURP) have also been commonly associated. Uncommon or rare causes of hematospermia include a vascular malformation in the pelvis or a tumor.

When due to a benign cause, the course of hematospermia is usually self limited. Sometimes, when associated with enlarged prostate in men older than forty, use of a five alpha reductase inhibitor such as proscar or Avodart are helpful in the faster resolution of symptoms.

Having practiced for 20 years, I still have not seen a patient with hematospermia due to a malignant cause in my practice. However, despite the fact that the majority of cases are due to benign causes, evaluation by a physician is still appropriate.

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