52 year male pt presented with hematospermia since last 1 month, also complaint of morning hematuria...

No luts,no burning,no hematuria,no fever
On examination- b/ l testies atrophic,prostate nodular
I/ v - urine rm- no pus cell,plenty of rbc in morning urine sample,no rbc in day time urine
Semen analysis- no sperm, plenty of rbc,no pus
Urine cast - no growth
Psa- .9
Usg kub- NAd
What next??
Provision diagnosis on history

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  • Utsav Shah
    Utsav Shah
    12 Mar 2020 08:19:59 PM

    Hematospermia is seen in normal individuals and also in GUTB.

    Need to examine the epididymis and spermatic cord: any beaded vas?

    Need quantification of WBC’s in the present semen analysis report. Also, Need to repeat semen analysis: It’s a well known fact that immature sperms and leukocytes are confused on semen analysis. Both are seen as ‘round cells’ on light microscopy and  for reliable differentiation staining techniques etc. need to be used. 

    Granulomatous Prostatitis is a differential for nodular Prostate. 

    Based on history and available investigations, I would suspect Genitourinary tuberculosis. 

    Needs further tests: Urine for AFB, QTF gold, CT urogram

  • Ashish parikh
    Ashish parikh
    12 Mar 2020 09:56:03 PM

    agree with Dr. Utsav

    most common causes apart from others (listed in table as attachment) are inflammatory, tumor and trauma.
    is there any past history of Tuberculosis, any history of trauma
    testis are atrophic - since childhood or any trauma? any lesion palpable in testis??
    nodular prostate - significant clinical findings. must rule out inflammatory pathology.
    i like to do ESR gene expert, semen culture and MRI pelvis
    Thanks and regards

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  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    15 Mar 2020 06:11:48 PM

    Dear Gaurav,
    Thanks a lot for posting the case.
    Few points discussed below may not be pertinent to the case being discussed. May be general observations or comments. I have tried to answer some of the queries raised by you. I hope, it is useful. Please revert back if you need clarification. And also give follow up. 
    Exclude Pseduohematospermia: Commonest mis diagnosis of hematospermia is intercourse during periods. It can happen when the lady has just started her periods when the intercourse took place. Another instance is if the person was wearing condom, we need to ask whether he saw blood inside or outside condom. Another possible mis diagnosis is intercourse trauma either to male or to female (deviant sexual practices). I presume that we have ruled out these causes.
    H/o pain in erection, pain in penetration may be suggestive of trauma. Pain during ejaculation would point towards inflammation in prostate.
    Misbeliefs: Too frequent or too infrequent intercourse was supposed to be a cause of hematospermia. But there is no conclusive evidence supporting this statement.
    Clinical classification: Hematospermia may be single episode, episodic/ sporadic or chronic. Your patient seems to be chronic.

    Hematospermia most commonly is self limiting. But considering age 52 and chronic hematospermia, this patient needs work up. But we should be aware that in spite of rigorous work up, around 10% to 70% of the cases of hematospermia turn out to be ‘idiopathic’ (various series).
    You have not mentioned the fertility of this gentleman, looking at azoospermia on semen analysis, I would be interested in knowing about it.
    High blood pressure is also one of the cause of hematospermia. I have seen two cases of accelerated hypertension presenting as hematospermia. Similarly coagulation profile may please be done (to complete the list …)
    The fact that patient complains of early morning hematuria points more towards some urethral cause. For this please do urine routine and microscopy of early, mid stream and terminal urine and see which of the specimens show (more) RBCs. Similarly VB1, VB2 samples would also be helpful. I have done VB1, VB2 analysis on a couple of occasions but did not find it to be of much yield. But hematospermia as such is so rare that you do not know where you may get a clue.
    TRUS is an important investigation in evaluation of hematospermia especially in men over 40 years. One of the large study by Zhao showed that we can get some positive finding in around 80% of the cases. However it cannot be conclusively sad that the same finding was the cause of hematospermia. Please see these references [1, 2,3,4,5] Especially read Zhao and Raviv
    Invasive transurethral vesiculography [7] has been described. In this study, authors prospectively enrolled 106 patients with persistent hematospermia of mean duration 20.5 months. All patients were evaluated by both transrectal ultrasonography and transurethral seminal vesiculoscopy after excluding definite etiological lesions beyond the reproductive duct system. The diagnostic yield of transurethral seminal vesiculoscopy for persistent hematospermia was significantly superior to that of transrectal ultrasonography, especially in lesions diagnosed with calculi and obstruction/stricture. Combining both modalities might provide extra benefits for patients with persistent hematospermia. So in our case if nothing is found we can resort to this investigation. I do not know how useful it would be. No personal experience
    Similarly CT and MRI have also been described. (No personal experience)
    If nothing is found, empirical antibiotics have been justified [6]. Fluoroquinolones + NSAIDs have been described as empirical treatment. In this study, 159 out of 165 patients treated with ciprofloxacin and celecoxib responded. Of the other six patients, 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. This article is worth reading.
    One thing that intrigues both patient and urologist is: Is this cancer?
    Yeung et al [8] published their experiences of 300 consecutive patients presenting as hematospermia. 13 prostate cancers were detected (5.7%) and 2 of dysplasia, all in men over 40 years either with a PSA of >3.0 ng/dl or an abnormal DRE. 
    A community based prostate cancer screening study [9] enrolled 26126 patients. In this study, Prostate cancer was detected in 1,708 of the 26,126 men (6.5%) who underwent prostate cancer screening. Prostate cancer was diagnosed in 19 of the 139 men (13.7%) who reported hemospermia upon entering the prostate cancer screening study. In the logistic regression model hemospermia was a significant predictor of prostate cancer diagnosis after adjusting for age, PSA and DRE results (OR 1.73, p = 0.054). Authors concluded that, Hemospermia is rare (0.5%) in a prostate cancer screening population. When a man presents with hemospermia, prostate cancer screening should be vigilantly performed since hemospermia is associated with an increased risk of prostate cancer.
    1. Yagci C, Kupeli S, Tok C, Fitoz S, Baltaci S, Gogus O. Efficacy of transrectal ultrasonography in the evaluation of hematospermia. Clinical imaging. 2004 Jul 1;28(4):286-90.
    2. Worischeck JH, Parra RO. Chronic hematospermia: assessment by transrectal ultrasound. Urology. 1994 Apr 1;43(4):515-20.
    3. Zhao H, Luo J, Wang D, Lu J, Zhong W, Wei J, Chen W. The value of transrectal ultrasound in the diagnosis of hematospermia in a large cohort of patients. Journal of andrology. 2012 Sep 10;33(5):897-903.
    4. Raviv G, Laufer M, Miki H. Hematospermia—the added value of transrectal ultrasound to clinical evaluation: Is transrectal ultrasound necessary for evaluation of hematospermia?. Clinical imaging. 2013 Sep 1;37(5):913-6.
    5. Kaplan SA. Re: Hematospermia—The Added Value of Transrectal Ultrasound to Clinical Evaluation: Is Transrectal Ultrasound Necessary for Evaluation of Hematospermia?. The Journal of urology. 2015.
    6. Zargooshi J, Nourizad S, Vaziri S, Nikbakht MR, Almasi A, Ghadiri K, Bidhendi S, Khazaie H, Motaee H, Malek-Khosravi S, Farshchian N. Hemospermia: long-term outcome in 165 patients. International journal of impotence research. 2014 May;26(3):83-6.
    7. Xing C, Zhou X, Xin L, Hu H, Li L, Fang J, Liu Z. Prospective trial comparing transrectal ultrasonography and transurethral seminal vesiculoscopy for persistent hematospermia. International Journal of Urology. 2012 May;19(5):437-42.
    8. Ng YH, Seeley JP, Smith G. Haematospermia as a presenting symptom: outcomes of investigation in 300 men. The Surgeon. 2013 Feb 1;11(1):35-8.
    9. Han M, Brannigan RE, Antenor JA, Roehl KA, Catalona WJ. Association of hemospermia with prostate cancer. The Journal of urology. 2004 Dec 1;172(6):2189-92.

  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    15 Mar 2020 06:18:52 PM

    flow chart from: Leocádio DE, Stein BS. Hematospermia: etiological and management considerations. International urology and nephrology. 2009 Mar 1;41(1):77-83.

  • Venugopal P
    Venugopal P
    16 Mar 2020 08:14:01 AM

    Dear All,

    We must thank Prashant for providing useful information regarding Haematospermia and some of the points mentioned are of considerable practical importance.

    He has given references for those interested in furthering their knowledge and we should appreciate his efforts.

    DK Pal (2006) studied haematospermia and found that most cases had a cause if it was persistent or recurring. He highlighted the importance of Tuberculosis as an important cause in India.

    Recently MRI and Transurethral Seminal Vesiculoscopy is gaining importance in the Diagnosis and treatment for recurrent/persistent haematospermia.

    I am providing links to few articles which could help all to understand the subject a bit more than what has been provided by Prashant.




    With warm regards,



  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    16 Mar 2020 09:00:17 PM

    Thanks a lot sir for the words of appreciation

  • JG Lalmalani
    JG Lalmalani
    18 Mar 2020 02:25:45 PM

    Appreciate all above comments.

    DRE, Semen Analysis and Culture, TRUS sonography and endoscopy are useful adjuncts.
    Most cases of Haemospermia do not end with definitive diagnosis and would land up with the diagnosis of Indiopathic Hamospermia.
    Most patients do brilliantly with a long course of antibiotics like Levofloxacin. I strongly recommend and have very good  results with the addition of Dutasteride.).5 mg 1 daily initially and once a week for a longer period of time, esp. in younger patients.

  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    18 Mar 2020 11:02:06 PM

    This is in response to the post by Dr Lalmalani about empirical use of dutasteride. We must take into consideration following things

    1.       This is an off label use of dutasteride. Patient should be informed accordingly

    2.       Dutasteride can cause erectile insufficiency

    3.       Dutasteride should not be used by patients whose partner is pregnant or likely to become pregnant

    4.       Pregnant lady should not handle crushed tablets of dutasteride



    Merck. PROSCAR (finasteride) Tablets [Internet]. 2013.. Available from: https://www.merck.com/product/usa/pi_circulars/p/proscar/proscar_pi.pdf

    GlaxoSmithKline. Avodart Prescribing information [Internet]. 2008.. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/021319s014lbl.pdf

  • Ravindra Sabnis
    Ravindra Sabnis
    19 Mar 2020 07:43:13 PM

    Dr. Prashant congrats for your research on hematospermia. Excellent information. Our experience of 27 cases, in majority cause was stones in EJD, calcification of EJD wall, None had tuberculosis/ malignancy. Few pts had concomitant EJD obst which was relieved by TURED. 

    Prashant has given guidelines which are most practical. TRUS is our mainstay in investigations. 

  • Venugopal P
    Venugopal P
    25 Mar 2020 08:01:47 AM

    Dear all,

    In continuation of the excellent discussion led by Prashant on haemospermia, I am providing an article which appeared today in BMC Urology. This is only an addition to the discussion already available


    With warm Regards,


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