madman
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Hematospermia Etiology, Diagnosis, Treatment, and Sexual Ramifications: A Narrative Review (2021)
Robert H. Drury, BS, Brendan King, MD, Bryan Herzog, MD, and Wayne J.G. Hellstrom, MD
ABSTRACT
Introduction: Hematospermia (HS) is the presence of blood in the ejaculatory fluid. It is a rare condition that is historically idiopathic or associated with sexual behavior. Technological advances have identified many of the etiologies behind HS, improving treatment. Though often benign, HS remains a source of considerable sexual anxiety for patients. Few papers have outlined a diagnostic and therapeutic approach to HS, and none have explicitly addressed its sexual consequences.
Objectives: To provide a comprehensive overview of HS, emphasizing its sexual ramifications.
Methods: A PubMed literature search was performed through May 2021 to identify all relevant publications related to etiology, diagnosis, treatment, and sexual effects of HS. Original research and reviews were analyzed, and pertinent studies were included in this review.
Results: Iatrogenic interventions (eg, transrectal ultrasound-guided prostate biopsies) are the most common cause of HS. Infection and/or nonspecific inflammation is the most common non-iatrogenic etiology. Malignancies, including prostate, testicular, and other genitourinary cancers, are rarely the cause of HS. Diagnostic approaches to HS can be organized according to patient age (less than or greater than 40 years old), the persistence of bleeding, and the presence/absence of concerning symptoms. Though HS often spontaneously resolves, treatment may require various medications (eg, antibiotics, anti-inflammatories) or surgical interventions. HS has several sexual ramifications, including libido-affecting anxiety, social repercussions from sexual partners and nonsexual affiliates, increased risk of erectile dysfunction or transmission of sexual infections, and compromised fertility, especially when cryopreservation is utilized.
Conclusion: HS may significantly affect sexual health through several mechanisms, though there is a paucity of formal data on this subject. Further research is needed to fully understand the severity and extent of HS’s effect on sexual well-being, especially in those with refractory bleeding.
INTRODUCTION
Hematospermia (HS), also referred to as hemospermia, is the presence of blood in the ejaculatory fluid. It is a relatively rare condition, accounting for < 1% of urologic referrals.1 The exact incidence is unknown, however, as it may be unnoticed or unreported by patients.2,3 The age of individuals presenting with HS varies significantly, ranging from 15 to 85 years old.2,4 Though it may occur as a single episode, HS can persist for months to years, depending on its underlying etiology.5,6
Historically, HS was often idiopathic or attributed to adverse sexual behavior, such as excessive sexual activity or prolonged abstinence.7-10 However, current imaging and diagnostic interventions have improved identification of its causes.10,11 In general, the etiologies of HS are usually transient and/or benign (eg, urogenital infections and/or inflammation, calculus, stricture),12- 14 though some men may have an underlying malignant cause of HS, especially if they are ≥ 40 years old.2,4,15 Even with its relatively small risk of associated malignancy, HS is often a source of great sexual anxiety for many men.11,16-18
Few publications have outlined a formal diagnostic and therapeutic approach to HS, and none have addressed its effect on sexual health. The intent of this review is to provide a comprehensive overview of HS, emphasizing its influence on sexual wellbeing.
Etiologies
The etiologies of HS vary greatly (Table 1). Iatrogenic causes, particularly transrectal ultrasound (TRUS)-guided prostate biopsies, are the most common current etiologies.19 According to two prospective studies, anywhere from 84% to 90% of patients will have HS following TRUS-guided prostate biopsies.20,21 However, some suggest the incidence is much smaller.22,23 HS following prostate biopsies usually appears as dark, old blood; bright, fresh blood may indicate bleeding from a different origin. Additional iatrogenic causes of HS include localized antibiotic injections for chronic bacterial prostatitis, transrectal high-intensity focused ultrasound for benign prostatic hyperplasia and prostate brachytherapy for low-risk prostate cancer.24-27
The most common non-iatrogenic etiologies of HS are infection and nonspecific inflammation, particularly of the prostate or seminal vesicles.28 For example, excluding patients with recent prostate biopsies, Ng et al. observed that the most diagnosed etiology of HS was an infection.12 This is especially true in patients less than 40 years old.10,18 These infections may be caused by numerous agents, including herpes simplex virus, Chlamydia trachomatis, Enterococcus faecalis, Ureaplasma urealyticum, Escherichia coli, Proteus mirabilis, and cytomegalovirus.2,29,30
For those in endemic areas, other rare infectious causes include schistosomes, Zika virus, and tuberculosis.31
Malignancy is a universally feared etiology of HS. Concern for cancer typically drives men to seek care after one episode of blood in their ejaculate.18 However, some researchers suggest the likelihood of malignancy in low-risk individuals is minimal.35 Several studies report various incidences of malignancy in patients with HS (Figure 2).
*Prostate and Testicular Cancer
*Other Urogenital Cancers. Malignancies of other GU
Diagnosis
HS can be initially assessed by a primary care physician. A single episode of blood in the semen can be managed conservatively by performing a GU-focused physical exam and obtaining labs (see subsections below). In the presence of concerning physical exam findings, abnormal labs, or high-risk factors, patients should be referred to a urologist.5,34 Additionally, for patients of any age presenting with HS and infertility, formal semen analysis and referral for a complete infertility evaluation should be undertaken.2
In general, the diagnostic workup can be grouped into two categories (Table 2). The first category includes patients with transient or episodic HS who are asymptomatic and < 40 years old. The age criteria of < 40 years old are based on this population’s low risk of malignancy.2,4,5 The second category includes patients who are ≥ 40 years, patients of any age with persistent HS, or patients of any age with HS accompanied by concerning symptoms or signs of disease. The distinction between transient or episodic HS and persistent HS is based on either the number of bloody ejaculates or duration. In general, persistent HS is defined as > 1 episode of HS, though this definition is not consistent throughout the literature.19,38
*Asymptomatic Patients < 40 Years Old
*Patients ≥40 Years Old, Persistent or Symptomatic HS
Treatment
In men of all ages, asymptomatic HS often resolves spontaneously without any pharmacologic or surgical interventions.28 In one prospective study, 88.9% of patients with painless, benign HS had spontaneous resolution of bleeding with a mean disease duration of 1.5 months.50 Thus, most patients with HS had symptom resolution without intervention. Additionally, a 2020 study revealed that approximately 90% of patients had a complete cure of their HS when the underlying etiology was treated.2 However, some patients still experience refractory HS (Table 3).
The principal aim of managing HS involves excluding serious diseases like prostate or bladder cancer and treating the underlying cause when identified. If the underlying pathology is not identified, then the practitioner should reassure the patient of the benign nature of idiopathic HS in most cases. Considering the causative factors and natural history of HS purported for various patient populations, management strategies largely depend on three factors: (i) the age of the patient, (ii) the duration and quality of HS, and (iii) the presence of associated symptoms.
*Treatment of HS in Patients < 40 Years
*Treatment of HS in Patients ≥ 40 Years
-Finasteride
-Transurethral Seminal Vesiculoscopy
-TRUS-Guided Transurethral Seminal Vesiculoscopy
-TRUS- and Fluoroscopic-Assisted Transurethral Incision of Ejaculatory Ducts
-Holmium Laser Incision Through a Ureteroscope
-Transcatheter Arterial Embolization
-Additional Procedures
Sexual Effects
Limited formal data exists on the sexual implications of HS. The inference is needed to understand how it may affect both individuals with bloody ejaculate and sexual partner(s). It does appear, however, that HS may affect sexual health in several ways.
In general, the effect of HS on sexual health is most likely related to the duration (eg, single episode vs recurrent bleeding) that someone experiences HS. In patients < 40 years old, HS tends to be a transient inflammatory or infectious condition that resolves spontaneously or with minimal intervention.2,10,12,18,29 A single episode of HS is less likely to cause significant sexual repercussions compared with continuous bleeding. In patients > 40 years old, a variety of etiologies exist for HS, some of which cause persistent bleeding.2,6,14,16,48 Rarely, prolonged bleeding may also occur in younger patients.34 In patients with either transient or prolonged bleeding, significant effort should be made to not only address the underlying cause of HS but also the sexual repercussions.
-Anxiety
-Social Implications
-Erectile Dysfunction
-Sexually Transmissible Infections
-Infertility
-Cryopreservation
CONCLUSION
HS is a rare GU concern that is usually benign. The diagnostic approach and treatment of HS differ based on age and underlying symptomatology and etiology. However, even after treatment, some still experience refractory bleeding. HS, especially prolonged or persistent bleeding, may significantly affect sexual health through several mechanisms, though there is a paucity of formal data on this subject. Further research is needed to better understand the severity and extent of HS’s effect on sexual wellbeing, especially in those with refractory symptoms.
Robert H. Drury, BS, Brendan King, MD, Bryan Herzog, MD, and Wayne J.G. Hellstrom, MD
ABSTRACT
Introduction: Hematospermia (HS) is the presence of blood in the ejaculatory fluid. It is a rare condition that is historically idiopathic or associated with sexual behavior. Technological advances have identified many of the etiologies behind HS, improving treatment. Though often benign, HS remains a source of considerable sexual anxiety for patients. Few papers have outlined a diagnostic and therapeutic approach to HS, and none have explicitly addressed its sexual consequences.
Objectives: To provide a comprehensive overview of HS, emphasizing its sexual ramifications.
Methods: A PubMed literature search was performed through May 2021 to identify all relevant publications related to etiology, diagnosis, treatment, and sexual effects of HS. Original research and reviews were analyzed, and pertinent studies were included in this review.
Results: Iatrogenic interventions (eg, transrectal ultrasound-guided prostate biopsies) are the most common cause of HS. Infection and/or nonspecific inflammation is the most common non-iatrogenic etiology. Malignancies, including prostate, testicular, and other genitourinary cancers, are rarely the cause of HS. Diagnostic approaches to HS can be organized according to patient age (less than or greater than 40 years old), the persistence of bleeding, and the presence/absence of concerning symptoms. Though HS often spontaneously resolves, treatment may require various medications (eg, antibiotics, anti-inflammatories) or surgical interventions. HS has several sexual ramifications, including libido-affecting anxiety, social repercussions from sexual partners and nonsexual affiliates, increased risk of erectile dysfunction or transmission of sexual infections, and compromised fertility, especially when cryopreservation is utilized.
Conclusion: HS may significantly affect sexual health through several mechanisms, though there is a paucity of formal data on this subject. Further research is needed to fully understand the severity and extent of HS’s effect on sexual well-being, especially in those with refractory bleeding.
INTRODUCTION
Hematospermia (HS), also referred to as hemospermia, is the presence of blood in the ejaculatory fluid. It is a relatively rare condition, accounting for < 1% of urologic referrals.1 The exact incidence is unknown, however, as it may be unnoticed or unreported by patients.2,3 The age of individuals presenting with HS varies significantly, ranging from 15 to 85 years old.2,4 Though it may occur as a single episode, HS can persist for months to years, depending on its underlying etiology.5,6
Historically, HS was often idiopathic or attributed to adverse sexual behavior, such as excessive sexual activity or prolonged abstinence.7-10 However, current imaging and diagnostic interventions have improved identification of its causes.10,11 In general, the etiologies of HS are usually transient and/or benign (eg, urogenital infections and/or inflammation, calculus, stricture),12- 14 though some men may have an underlying malignant cause of HS, especially if they are ≥ 40 years old.2,4,15 Even with its relatively small risk of associated malignancy, HS is often a source of great sexual anxiety for many men.11,16-18
Few publications have outlined a formal diagnostic and therapeutic approach to HS, and none have addressed its effect on sexual health. The intent of this review is to provide a comprehensive overview of HS, emphasizing its influence on sexual wellbeing.
Etiologies
The etiologies of HS vary greatly (Table 1). Iatrogenic causes, particularly transrectal ultrasound (TRUS)-guided prostate biopsies, are the most common current etiologies.19 According to two prospective studies, anywhere from 84% to 90% of patients will have HS following TRUS-guided prostate biopsies.20,21 However, some suggest the incidence is much smaller.22,23 HS following prostate biopsies usually appears as dark, old blood; bright, fresh blood may indicate bleeding from a different origin. Additional iatrogenic causes of HS include localized antibiotic injections for chronic bacterial prostatitis, transrectal high-intensity focused ultrasound for benign prostatic hyperplasia and prostate brachytherapy for low-risk prostate cancer.24-27
The most common non-iatrogenic etiologies of HS are infection and nonspecific inflammation, particularly of the prostate or seminal vesicles.28 For example, excluding patients with recent prostate biopsies, Ng et al. observed that the most diagnosed etiology of HS was an infection.12 This is especially true in patients less than 40 years old.10,18 These infections may be caused by numerous agents, including herpes simplex virus, Chlamydia trachomatis, Enterococcus faecalis, Ureaplasma urealyticum, Escherichia coli, Proteus mirabilis, and cytomegalovirus.2,29,30
For those in endemic areas, other rare infectious causes include schistosomes, Zika virus, and tuberculosis.31
Malignancy is a universally feared etiology of HS. Concern for cancer typically drives men to seek care after one episode of blood in their ejaculate.18 However, some researchers suggest the likelihood of malignancy in low-risk individuals is minimal.35 Several studies report various incidences of malignancy in patients with HS (Figure 2).
*Prostate and Testicular Cancer
*Other Urogenital Cancers. Malignancies of other GU
Diagnosis
HS can be initially assessed by a primary care physician. A single episode of blood in the semen can be managed conservatively by performing a GU-focused physical exam and obtaining labs (see subsections below). In the presence of concerning physical exam findings, abnormal labs, or high-risk factors, patients should be referred to a urologist.5,34 Additionally, for patients of any age presenting with HS and infertility, formal semen analysis and referral for a complete infertility evaluation should be undertaken.2
In general, the diagnostic workup can be grouped into two categories (Table 2). The first category includes patients with transient or episodic HS who are asymptomatic and < 40 years old. The age criteria of < 40 years old are based on this population’s low risk of malignancy.2,4,5 The second category includes patients who are ≥ 40 years, patients of any age with persistent HS, or patients of any age with HS accompanied by concerning symptoms or signs of disease. The distinction between transient or episodic HS and persistent HS is based on either the number of bloody ejaculates or duration. In general, persistent HS is defined as > 1 episode of HS, though this definition is not consistent throughout the literature.19,38
*Asymptomatic Patients < 40 Years Old
*Patients ≥40 Years Old, Persistent or Symptomatic HS
Treatment
In men of all ages, asymptomatic HS often resolves spontaneously without any pharmacologic or surgical interventions.28 In one prospective study, 88.9% of patients with painless, benign HS had spontaneous resolution of bleeding with a mean disease duration of 1.5 months.50 Thus, most patients with HS had symptom resolution without intervention. Additionally, a 2020 study revealed that approximately 90% of patients had a complete cure of their HS when the underlying etiology was treated.2 However, some patients still experience refractory HS (Table 3).
The principal aim of managing HS involves excluding serious diseases like prostate or bladder cancer and treating the underlying cause when identified. If the underlying pathology is not identified, then the practitioner should reassure the patient of the benign nature of idiopathic HS in most cases. Considering the causative factors and natural history of HS purported for various patient populations, management strategies largely depend on three factors: (i) the age of the patient, (ii) the duration and quality of HS, and (iii) the presence of associated symptoms.
*Treatment of HS in Patients < 40 Years
*Treatment of HS in Patients ≥ 40 Years
-Finasteride
-Transurethral Seminal Vesiculoscopy
-TRUS-Guided Transurethral Seminal Vesiculoscopy
-TRUS- and Fluoroscopic-Assisted Transurethral Incision of Ejaculatory Ducts
-Holmium Laser Incision Through a Ureteroscope
-Transcatheter Arterial Embolization
-Additional Procedures
Sexual Effects
Limited formal data exists on the sexual implications of HS. The inference is needed to understand how it may affect both individuals with bloody ejaculate and sexual partner(s). It does appear, however, that HS may affect sexual health in several ways.
In general, the effect of HS on sexual health is most likely related to the duration (eg, single episode vs recurrent bleeding) that someone experiences HS. In patients < 40 years old, HS tends to be a transient inflammatory or infectious condition that resolves spontaneously or with minimal intervention.2,10,12,18,29 A single episode of HS is less likely to cause significant sexual repercussions compared with continuous bleeding. In patients > 40 years old, a variety of etiologies exist for HS, some of which cause persistent bleeding.2,6,14,16,48 Rarely, prolonged bleeding may also occur in younger patients.34 In patients with either transient or prolonged bleeding, significant effort should be made to not only address the underlying cause of HS but also the sexual repercussions.
-Anxiety
-Social Implications
-Erectile Dysfunction
-Sexually Transmissible Infections
-Infertility
-Cryopreservation
CONCLUSION
HS is a rare GU concern that is usually benign. The diagnostic approach and treatment of HS differ based on age and underlying symptomatology and etiology. However, even after treatment, some still experience refractory bleeding. HS, especially prolonged or persistent bleeding, may significantly affect sexual health through several mechanisms, though there is a paucity of formal data on this subject. Further research is needed to better understand the severity and extent of HS’s effect on sexual wellbeing, especially in those with refractory symptoms.
