For haematospermia to occur, intact emission and ejaculation functions are necessary.⁴ The exact incidence of haematospermia remains unknown as most ejaculates go unnoticed during intercourse. It may be indicative of a significant underlying genito-urinary condition particularly in older patients where it may be a symptom of prostatic neoplasia. A methodical approach to its management, therefore, should be employed.⁵

Haematospermia should be investigated by a thorough clinical assessment and non-invasive investigations. The main aim is to exclude any underlying pathology and, if none is found, then to re-assure the patient after full evaluation.

There are two main aims in the evaluation: first, to ensure that there is no underlying sinister cause or a specific condition that is treatable thereby alleviating the patient's symptoms; second, to re-assure the patient if no causative factor is found. It is important, however, to make sure that the patient is actually describing haematospermia and not haematuria; in some cases, both may co-exist. If haematuria is present with haematospermia, the haematuria is investigated according to the standard protocols.

Most men with haematospermia are likely to be less than 40 years old with symptoms ranging from a few weeks to a few months in duration. The likelihood of recurrent haematospermia is seen in the older age group.

Sexually transmitted diseases may point to an infective cause such as urethritis, prostatitis, epididymitis, HIV or condylomata. Other infective causes include bilharziasis,⁶ cytomegalovirus⁷ and hydatid disease.⁸ Associated lower urinary tract symptoms should raise the possibility of a urethral stricture or a vascular and enlarged prostate. The patient is asked as to whether there was any trauma or self-instrumentation in the urogenital region. A history of prolonged and intense masturbation or sexual intercourse could lead to the congestion of genital organs and bleeding.

Transrectal ultrasound biopsy of the prostate is invariably associated with haematospermia. Systemic review should include any history of hypertension,⁹ renal, liver or bleeding disorders.⁵

Physical examination may help to locate the source of haematospermia. A full general examination including an assessment of blood pressure should be performed. The abdomen is examined for hepatosplenomegaly, masses and palpable bladder. The testes, epididymis, cord and penile urethra are carefully examined for inflammatory and neo-plastic pathology. The urethral meatus needs to be examined for the evidence of trauma, condylomata, phimosis and cancer. Testicular tumours may occasionally present with haematospermia.¹⁰ Testicular and epididymal examination will also reveal the presence of infective element including tuberculous disease. Palpation of the vasa deferentia may show thickening, induration or nodularity due to tuberculosis. Rectal examination will allow assessment of the prostate gland. Tenderness or induration of the prostate may imply infection whilst a hard texture or nodule may be indicative of neoplasia especially in an older individual.

If a sterile pyuria is noted then further investigations are required to exclude tuberculosis as an underlying pathology. Semen analysis may show the presence of pus cells which then warrants further investigation in search of an infectious aetiology; this includes semen culture, urethral swabs, mycobacterial cultures and viral serology.

It is necessary to stress to the patient that haematospermia is rarely associated with a significant pathology. In a younger patient less than 40 years of age with a single episode of haematospermia, clinical assessment with basic investigations to rule out any inflammation and infection in the genito-urinary system is sufficient.

Individuals with recurrent haematospermia and who are middle-aged need specialist urological assessment and investigations. If infection is suspected, a course of 5-aminoquinolones such as ciproxin or trimethoprim-sulphamethoxazole and doxycycline combination would be beneficial even if the urine cultures are negative.¹⁴ Systemic conditions are treated appropriately. Prostatic or seminal vesicular cysts can be aspirated under TRUS guidance. In recurrent haematospermia, cystourethroscopy may help to diagnose congested veins in the prostate and urethral abnormalities. Ejaculatory duct obstruction is managed by a transurethral incision at the duct opening.¹⁵