- Email: [email protected]
Hemospermia: diagnosis and management
CLINICAL
HEMOSPERMIA: JOHN
DIAGNOSIS
E MULHALL,
AND MANAGEMENT
M.D., AND PETER C. ALBERTSEN, M.D.
A
lthough often regarded as a symptom of little significance, blood in the ejaculate causes great consternation for many men. The condition is common, but since most episodes usually occur unnoticed, the prevalence of hemospermia remains unknown. For the majority of patients, no further diagnostic workup is needed, but for a minority of patients, this may be the harbinger of urologic disease. Physicians have diagnosed hemospermia (also known as hematospermia) for centuries. Hippocrates, Galen, Pare, Morgagni, and Fournier have all commented on this condition.lm3 The first American report appeared in 1894.4 Contemporary reports have been published by Fletcher et a1.,5 Leary and Aguilo, 6 Marshall and Fuller7 and Ganabathi et al.* Newer imaging modalities have altered both the diagnosis and treatment, prompting us to review the current English language medical literature. ETIOLOGY Hemospermia can result from many causes. A review of 506 cases from six large series shows that most men with this condition are young (mean age, 37 years) and have symptoms ranging in duration from 1 to 24 months.6,9-13 In up to 46% of cases, the etiology has been declared idiopathic, but this probably reflects incomplete evaluation of these patients. 5,8,14Infections or inflammatory disorders account for 39% of cases, and malignancies and trauma account for 2% each. The remaining 11% of cases were caused by a variety of other pathologic conditions. In this large group of patients, only 12% had concomitant hematuria. Hemospermia can appear as a single episode or can occur repeatedly over a period extending from several weeks to months. In Leary and Aguilo’s’j series, the majority of patients had multiple occurrences of hemospermia; 15% reported only a single episode. Jones,’ on the other hand, noted From the Department of Surgery, Division of Urology, University of Connecticut School of Medicine, Farmington, Connecticut Reprint requests: Peter C. Albertsen, M.D., Department of Surgery, Division of Urology, University of Connecticut Health Center, Farmington, CT 06030-3955 Submitted:January 17, 1995, accepted (with revisions): April 19,1995 UROLOGYB 46 (41, 1995
REVIEW
that most of his patients had only one or two episodes of hemospermia. Historically, hemospermia was linked to sexual behavior, and patients were warned about excessive overindulgence, prolonged sexual abstinence, interrupted coitus, and “unbridled license.“3,4 The advents of transrectal ultrasonography (TRUS) and magnetic resonance imaging (MRI) have afforded us the opportunity to visualize clearly the seminal vesicles, prostate, and ampullary portions of the vas. As a result, etiologic factors are now more frequently identified. Table I lists several potential pathologic causes of hemospermia. PROSTATE
Lesions of the prostate account for a large number of the cases of hemospermia and include polyps, vascular lesions, calculi, inflammatory disorders, and malignancies.6~9~‘4-‘hIn a series of 74 patients, most of whom were under 40 years of age, Jones9 cited prostatitis as a cause in 30% of patients. Hemospermia can also result from prostate telangiectasia and varices.9,14,15-18 One patient who had recurrent bouts of hemospermia and urinary retention was diagnosed as having prostate varices only after cystoscopic examination while experiencing an erection.9 Calculi found in patients’ ejaculates during investigation for hemospermia have been presumed by some to be the cause of these patients’ problems.13,16 The origin of these calculi is uncertain, but it has been most frequently ascribed to the prostate. Prostate cancer is rarely associated with hemospermia. Among the 74 patients reported by Jones, only 1 elderly patient was found to have prostate cancer after evaluation was complete. Fletcher et a1.5 identified 3 patients with prostate cancer among 81 identified with hemospermia. Tripathi and Dick17 have indicated that hemospermia may be the presenting complaint of urogenital sarcoma. With the increasing use of TRUS to guide prostate biopsies, a new cause for hemospermia has emerged. Several centers have reviewed complications associated with TRUS biopsies and report hemospermia to occur among 9% to 45% of patients.19-21Gustafsson et a1.,19in their review of 145 patients, reported hematuria in 39% of cases and hemospermia in 45%; 25% of men reported both symptoms. Collins et uI.,~O in their review of 89 patients, noted that 29% of patients had hemospermia. Hemospermia 463
lasted for less than 2 days in 11% of patients and between 2 and 7 days in the remaining 17% of patients. One person reported hemospermia lasting for as long as 6 weeks. In all three studies, the hemospermia was self-limited and required no specific therapy BLADDERAND URETHRA Urethritis has long been recognized as a cause of hemospermia, especially in younger men.9 Other urethral lesions leading to hemospermia include cysts, polyps, condylomata, and strictures. Benign urethral polyps can occur following failure of the invagination process of the prostatic glandular epithelium. In one case series, 20% of patients with urethral polyps had hemospermia as their presenting complaint.** a rare case of a Van Poppel et al. 23 described young man with hemospermia secondary to a utricular cyst. In another study, urethritis, condylomata, and stricture disease represented the cause of hemospermia in 7%, 1.5%, and 1.5% of cases, respectively.9 Hemospermia is rarely attributed to bladder disease. In their series of 81 patients, Fletcher et al.* identified only 2 patients with bladder tumors and 1 with a urethral tumor. SEMINAL VESICLES Numerous authors have cited congenital and acquired seminal vesicular cysts as a cause of hemospermia. 24-26 Congenital seminal vesicular cysts result from an error in embryologic development and are associated with either ipsilateral renal agenesis or ipsilateral congenital absence of the vas deferens. Acquired seminal vesicular cysts generally result from infectious processes.26 Malignancies of the seminal vesicles are a rare cause of hemospermia. In a review of 39 cases of primary carcinoma of the seminal vesicle, Benson et ~1.~~ reported that only 6 patients (16%) had hemospermia. The ages of these 6 patients ranged from 24 to 90 years. Kawahara et ~1.~~ reported 1 case of hemospermia resulting from papillary tubular adenocarcinoma, and Geoghegan and Bonavia29 reported a case of hemospermia resulting from a lymphoma invading the seminal vesicle. INFECTIONS Infectious causes of hemospermia include tuberculosis and cytomegalovirus infection.30,31 Several authors have reported schistosomiasis.8,32-34 Although these cases are often associated with extensive involvement of the bladder, Schistosoma haematobium ova are only occasionally found in the ejaculate. Hydatid disease, a parasitic infection caused by the echinococcus worm, has also been associated with hemospermia.35,36 464
UROLOGY”’ 46 (41, 1995
TRAUMA
Trauma has been cited as a cause of hemospermia in several case reports.5*9,12,37 Fletcher et a1.5 reported cases associated with testicular injury, Peyronie’s disease, and hemorrhoidal injection. Tolley and Castro12 reported on 2 cases associated with perineal trauma. Other reports cite hemospermia following urethral instrumentation during sexual foreplay and following “3-in-l” nerve block administered in the inguinal area prior to arthroscopic knee surgery.37 SYSTEMIC DISORDERS
Systemic disorders that are associated with hemospermia include hypertension, chronic liver disease, lymphoma, and bleeding diatheses.4,5J138-40 Although the prevalence of hemospermia was no higher than in the general population in one casecontrolled study of hypertension therapy, hemospermia resolved in several patients when the hypertension was controlled. Risk factors for the occurrence of hemospermia in hypertensive patients include severe uncontrolled hypertension, elevated serum creatinine, severe proteinuria, and renovascular disease.38 MISCELLANEOUS
Other causes of hemospermia include seminal vesicular amyloidosis, seminal vesiculovenous fistula, calculi within seminal vesicle diverticula, and ossification of the vas.5,8,27,41 Littrup et ~1.~~ found a statistically significant correlation between hemospermia and seminal vesicle and ejac-
TABLE II.
DIAGNOSIS
Urologists frequently use several tests in the evaluation of hemospermia (Table II). A good history that concentrates on trauma, infection, and bleeding disorders is often helpful in narrowing the differential diagnosis. The physical examination should include the patient’s blood pressure, because severe hypertension is associated with hemospermia. The penis should be carefully inspected to rule out any lesions that may bleed and contribute to the ejaculate. The vasa should be palpated along their entire course to ensure their presence and rule out any induration or nodularity. On digital rectal examination, special attention should be given to the seminal vesicles and the presence of any midline masses. A urinalysis and culture may prove helpful, because urogenital infections are frequently associated with hemospermia.5 Unfortunately the incidence of positive cultures is low, varying from 6% to 29°b.5 If the history suggests exposure to tuberculosis, urine culture for acid-fast bacillus may prove helpful, because tuberculosis has been cited as a cause of hemospermia in as many as 13% of cases in some series.13 In younger men, urethritis should be considered in the differential diagnosis, and urethral swabs should be taken to exclude nonspecific and gonococcal urethritis. Blood in the urine mandates a more extensive evaluation of the genitourinary tract.
Investigations
for hemospermia
Evaluation History (Focus on trauma, infection, bleeding disorders)
Usefulness Narrows differential
Physical examination (Focus on blood pressure, penis, vasa, prostate, seminal vesicles)
Occasionally
identifies
Urinalysis/Urine
Occasionally
identify infection
culture
Semen analysis
Confirms diagnosis
Semen culture
Rarely helpful
Laboratory
Limit to evaluation
analyses
diagnoses
pathology
for bleeding
disorders
Transrectal ultrasound/Cystourethroscopy
Can identify possible etiology, rarely leads to treatment recommendation beyond reassurance
Magnetic
Can demonstrate
resonance
imaging
VasographyAntravenous urogram/Seminal vesicuIographylComputed tomography scan UFVOLCXF
ulatory duct calculi. Lamesh43 reported on 1 case of a man who had hemospermia on exertion and who was found to have von Willebrand’s disease.
46 (4), 199.5
seminal vesicle hemorrhage
Rarely, if ever, helpful
465
The role of semen analysis and culture remains unclear. Although advocated by some authors, the significance of a positive culture remains uncertain, Because this may simply represent urethral contamination. Semen analysis may prove helpful in the differentiation of true hemospermia from other causes of ejaculate discoloration. Smith et al.44 have reported on 2 cases of melanospermia as the presenting feature of malignant melanoma. Melanin produces a dark brown or black discoloration of semen rather than the red or pink that occurs with hemospermia. If necessary, the two can be differentiated by chromatography.44 Laboratory analyses should otherwise be limited to an evaluation for bleeding disorders. l”,ll The advent of TRUS has provided physicians with the single most important new tool for the evaluation of hemospermia. Two large series have recently evaluated the utility of TRUS in the investigation of patients with chronic hemospermia. In a study of 52 patients, Etherington et ~1.~~ found a significant number of patients with prostate calculi and abnormalities of the seminal vesicles, including calculi, dilation, cysts, abnormal lobulation, and asymmetry More recently, Worischeck and Parra evaluated 26 patients with hemospermia using TRUS. They found abnormalities in 92% of patients, including dilated seminal vesicles (30%)) ejaculatory duct cysts (15%), ejaculatory duct calculi (15%)) seminal vesicle calculi ( 15%)) and mullerian duct remnants (7%). No sonographic evidence of malignancy was found in either series. The incidence of seminal vesicle abnormalities in these two series is similar to earlier studies using biochemical assays and seminal vesiculography.2sx47 In the absence of any urogenital infection or other discernible etiology, cystourethroscopy may aid the clinician in pinpointing the source of bleeding, since hemospermia can be associated with urethral and prostate lesions. Studies such as intravenous urography, vasography, and seminal vesiculography provide little additional information and should rarely be used. Maeda et ~1.~~ used MRI to study men with hemospermia. They found abnormalities, including cyst formation or dilation, in 14 of 15 patients. The best delineation of the seminal vesicles and their surrounding structures was achieved by T,weighted imaging. MRI can detect changes in anatomic structure secondary to endocrine therapy, radiation, inflammatory disorders, or neoplasia, but the biggest advantage of MRI over TRUS is its ability to demonstrate hemorrhage within the seminal vesicles or prostate.48 To date, no study utilizing an endorectal coil for the evaluation of the patient with hemospermia has been published. Although computed tomography has been used to study the morphology of the seminal vesi466
cles 49~50 no studies have been published that specifically target men with hemospermia. Intravenous urography is now probably only of historical interest. Earlier reviews have demonstrated little value to this imaging modality in the evaluation of the hemospermic male.*O TREATMENT
The primary goal of the urologist is to allay the anxiety of the frightened patient, because hemospermia is rarely associated with any significant abnormality, especially in younger men. Two factors dictate the extent of the evaluation and treatment: (1) the duration and recurrence of the hemospermia, and (2) the presence of any associated hematuria. Most clinicians agree that chronic hemospermia warrants more aggressive intervention to identify an etiologic factor, but there is little data to support this recommendation. Malignancies are relatively rare, occurring among only 13 of the 305 cases of hemospermia reported. Treatment is predicated on diagnostic findings. Urogenital infections require an appropriate antibiotic therapy, which normally resolves the problem.9 Urethral or prostate varices are best fulgurated, whereas cysts either of the seminal vesicles or prostatic urethra can be aspirated transrectally. Fuse and colleagues14 have injected coagulant substances into dilated seminal vesicles under TRUS guidance in 7 patients with hemospermia. The hemospermia was transiently resolved by this maneuver for a maximum duration of 3 months, at which time it recurred. At this time, therefore, there is no evidence that the injection of any substance, coagulant or sclerosing, has any role in the management of hemospermia. Bleeding diatheses or other systemic disorders should be treated in the appropriate manner. There is currently no rationale for the use of oral agents, such as estrogens or corticotropins, that have been used in the past.30,51 COMMENT
Hemospermia is a benign, but alarming, symptom for many men. Although the differential diagnosis is extensive (Table I), most cases result from infections or other inflammatory processes. The majority of patients can be evaluated by simply checking the blood pressure and performing a urinalysis. Patients with persistent hemospermia are those most likely to benefit from additional studies. They are best evaluated using TRUS or cystoscopy. Treatment depends on the diagnostic findings but often simply involves reassurance. REFERENCES 1. Hugues J: La pathogenia de l’hemospermia. Med Paris 41: 113-115, 1894.
Gaz Hebd
uROLGGY@46 (4), 1995
2. Kotsyn I: On bloody semen. Russk Med St Petersburg 18: 136-138, 1893. 3. Parker G: Hemospermia. Proc R Sot Med 35: 659-662, 1942. 4. Ross JC: Hemospermia. Practitioner 203: 59-62,1969. 5. Fletcher MS, Herzberg Z, and Pryor JR: The aetiology and investigation of hemospermia. Br J Urol 53: 669-671, 1981. 6. Leary FJ, and Aguilo JJ: Clinical significance of hemospermia. Mayo Clin Proc 49: 815-817, 1974. 7. Marshall VF, and Fuller NL: Hemospermia. J Ural 129: 377-378, 1981. 8. Ganabathi K, Chadwick D, Feneley RC, and Gingell JC: Hemospermia. Br J Uro169: 225-230, 1992. 9. Jones DJ: Hemospermia: a prospective study. Br J Urol 67: 88-90, 1991. 10. Weidner W, Jantos C, Schumacher F, Schiefer HG, and Meyhofer W: Recurrent hemospermia: underlying urogenital anomalies and efficacy of imaging procedures. Br J Urol 67: 317-323, 1991. 11. Yu HH, Wong KK, Lim TK, and Leong CH: Clinical study of hemospermia. Urology 10: 562-563, 1977. 12. Tolley DA, and Castro JE: Hemospermia. Urology 6: 331-332, 1975. 13. Papp G, and Molnar J: Causes and differential diagnosis of hematospermia. Andrologia 13: 474478, 1981. 14. Fuse H, Sumiya H, lshii H, and Shimazaki J: Treatment of hemospermia caused by dilated seminal vesicles by direct drug injection guided by ultrasonography. J Urol 140: 991-992, 1988. 15. Cattolica EV: Massive hemospermia: a new etiology and simplified treatment. J Urol 132: 120-123, 1984. 16. Widdison Al, and Feneley RC: Case report: calculi in the ejaculate. Br J Sex Med 16: 270-271, 1989. 17. Tripathi VN, and Dick VS: Primary sarcoma of the urogenital system in adults. J Urol 101: 898-904, 1969. 18. Stein AJ, Prioleau PG, and Catalona WJ: Adenomatous polyps of the prostatic urethra: a cause of hematospermia. J Urol 124: 298-299, 1980. 19. Gustafsson 0, Norming U, Nyman CR, and Cjhstrom M: Complications following combined transrectal aspiration and core biopsy of the prostate. Stand J Urol Nephrol 24: 249-251, 1990. 20. Collins GN, Lloyd SN, Hehir M, and McKelvie GB: Multiple transrectal ultrasound-guided prostatic biopsies-true morbidity and patient acceptance. Br J Urol71: 460463, 1993. 21. Aus G, Hermannson G, Hugosson J, and Pedersen KV: Transrectal ultrasound examination of the prostate: complications and acceptance by patients. Br J Urol71: 457459, 1993. 22. Walsh IK, Keane PF, and Herron B: Benign urethral polyps. Br J Urol 72: 937-938, 1993. 23. Van Poppel H, Vereecken R, De Geeter P, and Verduyn H: Hemospermia owing to utricular cyst: embryological summary and surgical review. J Urol129: 608609,1983. 24. Pryor JP: Hemospermia, in Whitfield HN, and Hendry WF (Eds): Textbook of Genitourinary Surgery, Edinburgh, Churchill Livingstone, 1985, pp 12081211. 25. Ogreid P, and Hatteland K: Cyst of the seminal vesicle associated with ipsilateral agenesis. Stand J Urol Nephrol 13: 113-116, 1989. 26. Heller E, and Whitesel JA: Seminal vesicle cysts. J Urol 90: 305-307, 1963. 27. Benson RC Jr, Clark WR, and Farrow GM: Carcinoma of the seminal vesicle. J Urol 132: 483485, 1984.
UROLOGY@ 46 (41, 1995
28. Kawahara M, Matsuhashi M, Tajima M, Sawamura Y, Matsushima M, Shirai M, and Ando K: Primary carcinoma of the seminal vesicles. Diagnosis assisted by sonography. Urology 32: 269-272, 1988. 29. Geoghegan JG, and Bonavia I: Hemospermia as a presenting symptom of lymphoma. Br J Urol 66: 658, 1990. 30. Yada B: On the study of hemospermia. Acta Urol Jpn 9: 175-205, 1989. 31. Koment RW, and Poor PM: Infection by human cytomegalovirus associated with chronic hematospermia. Urology 22: 617-621, 1983. 32. Ashkar MF, and lssa II: Bilharzial hemospermia. J Egypt Med Assoc 18: 274, 1935. 33. Elem B, and Patil PS: Hemospermia: observations in an area of endemic bilharziasis. Br J Urol 60: 170-173, 1987. 34. Lembeli CM, and Venkataramaiah NR: Re: Schistosoma haematobium ova in semen. J Urol 125: 603, 1981. 35. Halim A, and Vaezzadeh K: Hydatid disease of the genitourinary tract. Br J Urol 52: 75-78, 1980. 36. Whyman MR, and Morris DL: Retrovesical hydatid causing hemospermia. Br J Urol 68: 100-101, 1991. 37. Craig SR: “3-in-l” nerve block complicated by hemospermia. Br J Clin Pratt 46: 80, 1992. 38. Close CF, Yeo WW, and Ramsay LE: The association between hemospermia and severe hypertension. Postgrad Med J 67: 157-158, 1991. 39. lversen PS: Hemospermia and hypertension. Ugeskr Laeger 149: 596, 1987. 40. Hamburger S, Styczynski M, O’Heame J, and German G: Hemospermia and hypertension: two case reports. J Kansas Med Sot 81: 459460, 1980. 41. Magid MA, and Hejtmancik JH: Hemospermia. J Urol 78: 82-88, 1957. 42. Littrup PJ, Lee F, McLeary RD, Wu D, Lee A, and Kumasaka GH: Transrectal US of the seminal vesicles and ejaculatory ducts: clinical correlation. Radiology 168: 625-628, 1988. 43. Lamesh RA: Recurrent hematuria and hematospermia due to prostatic telangiectasia in classic von Willebrand’s disease. Am J Med Sci 306: 35-36, 1993. 44. Smith GW, Griffith DP, and Pranke DW: Melanospermia: an unusual presentation of malignant melanoma. J Urol 110: 314-316, 1973. 45. Etherington RJ, Clements R, Griffiths GJ, and Peeling WB: Transrectal ultrasound in the investigation of hemospermia. Clin Radio1 41: 175-177, 1990. 46. Worischeck JH, and Parra RO: Chronic hematospermia: assessment by transrectal ultrasound. Urology 43: 515-520, 1994. 47. Maeda H, Toyooka N, Kinukawa T, Hattori R, and Furakawa T: Magnetic resonance images of hematospermia. Urology 41: 499-504, 1993. 48. Secaf E, Nuruddin RN, Hricak H, McClure RD, and Demas B: MR imaging of the seminal vesicles. AJR Am J Roentgen01 156: 989-994, 1991. 49. Kenney PJ, and Leeson MD: Congenital anomalies of the seminal vesicles: spectrum of computed tomographic findings. Radiology 149: 247-251, 1983. 50. Silverman PM, Dunnick NR, and Ford KK: Computed tomography of the normal seminal vesicles. Comput Radio1 9: 379-385, 1985. 51. Huggins C, and McDonald DF: Chronic hemospermia: its origin and treatment with estrogen. J Clin Endocrinol 5: 226-231, 1945.
467
HEMOSPERMIA: JOHN
DIAGNOSIS
E MULHALL,
AND MANAGEMENT
M.D., AND PETER C. ALBERTSEN, M.D.
A
lthough often regarded as a symptom of little significance, blood in the ejaculate causes great consternation for many men. The condition is common, but since most episodes usually occur unnoticed, the prevalence of hemospermia remains unknown. For the majority of patients, no further diagnostic workup is needed, but for a minority of patients, this may be the harbinger of urologic disease. Physicians have diagnosed hemospermia (also known as hematospermia) for centuries. Hippocrates, Galen, Pare, Morgagni, and Fournier have all commented on this condition.lm3 The first American report appeared in 1894.4 Contemporary reports have been published by Fletcher et a1.,5 Leary and Aguilo, 6 Marshall and Fuller7 and Ganabathi et al.* Newer imaging modalities have altered both the diagnosis and treatment, prompting us to review the current English language medical literature. ETIOLOGY Hemospermia can result from many causes. A review of 506 cases from six large series shows that most men with this condition are young (mean age, 37 years) and have symptoms ranging in duration from 1 to 24 months.6,9-13 In up to 46% of cases, the etiology has been declared idiopathic, but this probably reflects incomplete evaluation of these patients. 5,8,14Infections or inflammatory disorders account for 39% of cases, and malignancies and trauma account for 2% each. The remaining 11% of cases were caused by a variety of other pathologic conditions. In this large group of patients, only 12% had concomitant hematuria. Hemospermia can appear as a single episode or can occur repeatedly over a period extending from several weeks to months. In Leary and Aguilo’s’j series, the majority of patients had multiple occurrences of hemospermia; 15% reported only a single episode. Jones,’ on the other hand, noted From the Department of Surgery, Division of Urology, University of Connecticut School of Medicine, Farmington, Connecticut Reprint requests: Peter C. Albertsen, M.D., Department of Surgery, Division of Urology, University of Connecticut Health Center, Farmington, CT 06030-3955 Submitted:January 17, 1995, accepted (with revisions): April 19,1995 UROLOGYB 46 (41, 1995
REVIEW
that most of his patients had only one or two episodes of hemospermia. Historically, hemospermia was linked to sexual behavior, and patients were warned about excessive overindulgence, prolonged sexual abstinence, interrupted coitus, and “unbridled license.“3,4 The advents of transrectal ultrasonography (TRUS) and magnetic resonance imaging (MRI) have afforded us the opportunity to visualize clearly the seminal vesicles, prostate, and ampullary portions of the vas. As a result, etiologic factors are now more frequently identified. Table I lists several potential pathologic causes of hemospermia. PROSTATE
Lesions of the prostate account for a large number of the cases of hemospermia and include polyps, vascular lesions, calculi, inflammatory disorders, and malignancies.6~9~‘4-‘hIn a series of 74 patients, most of whom were under 40 years of age, Jones9 cited prostatitis as a cause in 30% of patients. Hemospermia can also result from prostate telangiectasia and varices.9,14,15-18 One patient who had recurrent bouts of hemospermia and urinary retention was diagnosed as having prostate varices only after cystoscopic examination while experiencing an erection.9 Calculi found in patients’ ejaculates during investigation for hemospermia have been presumed by some to be the cause of these patients’ problems.13,16 The origin of these calculi is uncertain, but it has been most frequently ascribed to the prostate. Prostate cancer is rarely associated with hemospermia. Among the 74 patients reported by Jones, only 1 elderly patient was found to have prostate cancer after evaluation was complete. Fletcher et a1.5 identified 3 patients with prostate cancer among 81 identified with hemospermia. Tripathi and Dick17 have indicated that hemospermia may be the presenting complaint of urogenital sarcoma. With the increasing use of TRUS to guide prostate biopsies, a new cause for hemospermia has emerged. Several centers have reviewed complications associated with TRUS biopsies and report hemospermia to occur among 9% to 45% of patients.19-21Gustafsson et a1.,19in their review of 145 patients, reported hematuria in 39% of cases and hemospermia in 45%; 25% of men reported both symptoms. Collins et uI.,~O in their review of 89 patients, noted that 29% of patients had hemospermia. Hemospermia 463
lasted for less than 2 days in 11% of patients and between 2 and 7 days in the remaining 17% of patients. One person reported hemospermia lasting for as long as 6 weeks. In all three studies, the hemospermia was self-limited and required no specific therapy BLADDERAND URETHRA Urethritis has long been recognized as a cause of hemospermia, especially in younger men.9 Other urethral lesions leading to hemospermia include cysts, polyps, condylomata, and strictures. Benign urethral polyps can occur following failure of the invagination process of the prostatic glandular epithelium. In one case series, 20% of patients with urethral polyps had hemospermia as their presenting complaint.** a rare case of a Van Poppel et al. 23 described young man with hemospermia secondary to a utricular cyst. In another study, urethritis, condylomata, and stricture disease represented the cause of hemospermia in 7%, 1.5%, and 1.5% of cases, respectively.9 Hemospermia is rarely attributed to bladder disease. In their series of 81 patients, Fletcher et al.* identified only 2 patients with bladder tumors and 1 with a urethral tumor. SEMINAL VESICLES Numerous authors have cited congenital and acquired seminal vesicular cysts as a cause of hemospermia. 24-26 Congenital seminal vesicular cysts result from an error in embryologic development and are associated with either ipsilateral renal agenesis or ipsilateral congenital absence of the vas deferens. Acquired seminal vesicular cysts generally result from infectious processes.26 Malignancies of the seminal vesicles are a rare cause of hemospermia. In a review of 39 cases of primary carcinoma of the seminal vesicle, Benson et ~1.~~ reported that only 6 patients (16%) had hemospermia. The ages of these 6 patients ranged from 24 to 90 years. Kawahara et ~1.~~ reported 1 case of hemospermia resulting from papillary tubular adenocarcinoma, and Geoghegan and Bonavia29 reported a case of hemospermia resulting from a lymphoma invading the seminal vesicle. INFECTIONS Infectious causes of hemospermia include tuberculosis and cytomegalovirus infection.30,31 Several authors have reported schistosomiasis.8,32-34 Although these cases are often associated with extensive involvement of the bladder, Schistosoma haematobium ova are only occasionally found in the ejaculate. Hydatid disease, a parasitic infection caused by the echinococcus worm, has also been associated with hemospermia.35,36 464
UROLOGY”’ 46 (41, 1995
TRAUMA
Trauma has been cited as a cause of hemospermia in several case reports.5*9,12,37 Fletcher et a1.5 reported cases associated with testicular injury, Peyronie’s disease, and hemorrhoidal injection. Tolley and Castro12 reported on 2 cases associated with perineal trauma. Other reports cite hemospermia following urethral instrumentation during sexual foreplay and following “3-in-l” nerve block administered in the inguinal area prior to arthroscopic knee surgery.37 SYSTEMIC DISORDERS
Systemic disorders that are associated with hemospermia include hypertension, chronic liver disease, lymphoma, and bleeding diatheses.4,5J138-40 Although the prevalence of hemospermia was no higher than in the general population in one casecontrolled study of hypertension therapy, hemospermia resolved in several patients when the hypertension was controlled. Risk factors for the occurrence of hemospermia in hypertensive patients include severe uncontrolled hypertension, elevated serum creatinine, severe proteinuria, and renovascular disease.38 MISCELLANEOUS
Other causes of hemospermia include seminal vesicular amyloidosis, seminal vesiculovenous fistula, calculi within seminal vesicle diverticula, and ossification of the vas.5,8,27,41 Littrup et ~1.~~ found a statistically significant correlation between hemospermia and seminal vesicle and ejac-
TABLE II.
DIAGNOSIS
Urologists frequently use several tests in the evaluation of hemospermia (Table II). A good history that concentrates on trauma, infection, and bleeding disorders is often helpful in narrowing the differential diagnosis. The physical examination should include the patient’s blood pressure, because severe hypertension is associated with hemospermia. The penis should be carefully inspected to rule out any lesions that may bleed and contribute to the ejaculate. The vasa should be palpated along their entire course to ensure their presence and rule out any induration or nodularity. On digital rectal examination, special attention should be given to the seminal vesicles and the presence of any midline masses. A urinalysis and culture may prove helpful, because urogenital infections are frequently associated with hemospermia.5 Unfortunately the incidence of positive cultures is low, varying from 6% to 29°b.5 If the history suggests exposure to tuberculosis, urine culture for acid-fast bacillus may prove helpful, because tuberculosis has been cited as a cause of hemospermia in as many as 13% of cases in some series.13 In younger men, urethritis should be considered in the differential diagnosis, and urethral swabs should be taken to exclude nonspecific and gonococcal urethritis. Blood in the urine mandates a more extensive evaluation of the genitourinary tract.
Investigations
for hemospermia
Evaluation History (Focus on trauma, infection, bleeding disorders)
Usefulness Narrows differential
Physical examination (Focus on blood pressure, penis, vasa, prostate, seminal vesicles)
Occasionally
identifies
Urinalysis/Urine
Occasionally
identify infection
culture
Semen analysis
Confirms diagnosis
Semen culture
Rarely helpful
Laboratory
Limit to evaluation
analyses
diagnoses
pathology
for bleeding
disorders
Transrectal ultrasound/Cystourethroscopy
Can identify possible etiology, rarely leads to treatment recommendation beyond reassurance
Magnetic
Can demonstrate
resonance
imaging
VasographyAntravenous urogram/Seminal vesicuIographylComputed tomography scan UFVOLCXF
ulatory duct calculi. Lamesh43 reported on 1 case of a man who had hemospermia on exertion and who was found to have von Willebrand’s disease.
46 (4), 199.5
seminal vesicle hemorrhage
Rarely, if ever, helpful
465
The role of semen analysis and culture remains unclear. Although advocated by some authors, the significance of a positive culture remains uncertain, Because this may simply represent urethral contamination. Semen analysis may prove helpful in the differentiation of true hemospermia from other causes of ejaculate discoloration. Smith et al.44 have reported on 2 cases of melanospermia as the presenting feature of malignant melanoma. Melanin produces a dark brown or black discoloration of semen rather than the red or pink that occurs with hemospermia. If necessary, the two can be differentiated by chromatography.44 Laboratory analyses should otherwise be limited to an evaluation for bleeding disorders. l”,ll The advent of TRUS has provided physicians with the single most important new tool for the evaluation of hemospermia. Two large series have recently evaluated the utility of TRUS in the investigation of patients with chronic hemospermia. In a study of 52 patients, Etherington et ~1.~~ found a significant number of patients with prostate calculi and abnormalities of the seminal vesicles, including calculi, dilation, cysts, abnormal lobulation, and asymmetry More recently, Worischeck and Parra evaluated 26 patients with hemospermia using TRUS. They found abnormalities in 92% of patients, including dilated seminal vesicles (30%)) ejaculatory duct cysts (15%), ejaculatory duct calculi (15%)) seminal vesicle calculi ( 15%)) and mullerian duct remnants (7%). No sonographic evidence of malignancy was found in either series. The incidence of seminal vesicle abnormalities in these two series is similar to earlier studies using biochemical assays and seminal vesiculography.2sx47 In the absence of any urogenital infection or other discernible etiology, cystourethroscopy may aid the clinician in pinpointing the source of bleeding, since hemospermia can be associated with urethral and prostate lesions. Studies such as intravenous urography, vasography, and seminal vesiculography provide little additional information and should rarely be used. Maeda et ~1.~~ used MRI to study men with hemospermia. They found abnormalities, including cyst formation or dilation, in 14 of 15 patients. The best delineation of the seminal vesicles and their surrounding structures was achieved by T,weighted imaging. MRI can detect changes in anatomic structure secondary to endocrine therapy, radiation, inflammatory disorders, or neoplasia, but the biggest advantage of MRI over TRUS is its ability to demonstrate hemorrhage within the seminal vesicles or prostate.48 To date, no study utilizing an endorectal coil for the evaluation of the patient with hemospermia has been published. Although computed tomography has been used to study the morphology of the seminal vesi466
cles 49~50 no studies have been published that specifically target men with hemospermia. Intravenous urography is now probably only of historical interest. Earlier reviews have demonstrated little value to this imaging modality in the evaluation of the hemospermic male.*O TREATMENT
The primary goal of the urologist is to allay the anxiety of the frightened patient, because hemospermia is rarely associated with any significant abnormality, especially in younger men. Two factors dictate the extent of the evaluation and treatment: (1) the duration and recurrence of the hemospermia, and (2) the presence of any associated hematuria. Most clinicians agree that chronic hemospermia warrants more aggressive intervention to identify an etiologic factor, but there is little data to support this recommendation. Malignancies are relatively rare, occurring among only 13 of the 305 cases of hemospermia reported. Treatment is predicated on diagnostic findings. Urogenital infections require an appropriate antibiotic therapy, which normally resolves the problem.9 Urethral or prostate varices are best fulgurated, whereas cysts either of the seminal vesicles or prostatic urethra can be aspirated transrectally. Fuse and colleagues14 have injected coagulant substances into dilated seminal vesicles under TRUS guidance in 7 patients with hemospermia. The hemospermia was transiently resolved by this maneuver for a maximum duration of 3 months, at which time it recurred. At this time, therefore, there is no evidence that the injection of any substance, coagulant or sclerosing, has any role in the management of hemospermia. Bleeding diatheses or other systemic disorders should be treated in the appropriate manner. There is currently no rationale for the use of oral agents, such as estrogens or corticotropins, that have been used in the past.30,51 COMMENT
Hemospermia is a benign, but alarming, symptom for many men. Although the differential diagnosis is extensive (Table I), most cases result from infections or other inflammatory processes. The majority of patients can be evaluated by simply checking the blood pressure and performing a urinalysis. Patients with persistent hemospermia are those most likely to benefit from additional studies. They are best evaluated using TRUS or cystoscopy. Treatment depends on the diagnostic findings but often simply involves reassurance. REFERENCES 1. Hugues J: La pathogenia de l’hemospermia. Med Paris 41: 113-115, 1894.
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2. Kotsyn I: On bloody semen. Russk Med St Petersburg 18: 136-138, 1893. 3. Parker G: Hemospermia. Proc R Sot Med 35: 659-662, 1942. 4. Ross JC: Hemospermia. Practitioner 203: 59-62,1969. 5. Fletcher MS, Herzberg Z, and Pryor JR: The aetiology and investigation of hemospermia. Br J Urol 53: 669-671, 1981. 6. Leary FJ, and Aguilo JJ: Clinical significance of hemospermia. Mayo Clin Proc 49: 815-817, 1974. 7. Marshall VF, and Fuller NL: Hemospermia. J Ural 129: 377-378, 1981. 8. Ganabathi K, Chadwick D, Feneley RC, and Gingell JC: Hemospermia. Br J Uro169: 225-230, 1992. 9. Jones DJ: Hemospermia: a prospective study. Br J Urol 67: 88-90, 1991. 10. Weidner W, Jantos C, Schumacher F, Schiefer HG, and Meyhofer W: Recurrent hemospermia: underlying urogenital anomalies and efficacy of imaging procedures. Br J Urol 67: 317-323, 1991. 11. Yu HH, Wong KK, Lim TK, and Leong CH: Clinical study of hemospermia. Urology 10: 562-563, 1977. 12. Tolley DA, and Castro JE: Hemospermia. Urology 6: 331-332, 1975. 13. Papp G, and Molnar J: Causes and differential diagnosis of hematospermia. Andrologia 13: 474478, 1981. 14. Fuse H, Sumiya H, lshii H, and Shimazaki J: Treatment of hemospermia caused by dilated seminal vesicles by direct drug injection guided by ultrasonography. J Urol 140: 991-992, 1988. 15. Cattolica EV: Massive hemospermia: a new etiology and simplified treatment. J Urol 132: 120-123, 1984. 16. Widdison Al, and Feneley RC: Case report: calculi in the ejaculate. Br J Sex Med 16: 270-271, 1989. 17. Tripathi VN, and Dick VS: Primary sarcoma of the urogenital system in adults. J Urol 101: 898-904, 1969. 18. Stein AJ, Prioleau PG, and Catalona WJ: Adenomatous polyps of the prostatic urethra: a cause of hematospermia. J Urol 124: 298-299, 1980. 19. Gustafsson 0, Norming U, Nyman CR, and Cjhstrom M: Complications following combined transrectal aspiration and core biopsy of the prostate. Stand J Urol Nephrol 24: 249-251, 1990. 20. Collins GN, Lloyd SN, Hehir M, and McKelvie GB: Multiple transrectal ultrasound-guided prostatic biopsies-true morbidity and patient acceptance. Br J Urol71: 460463, 1993. 21. Aus G, Hermannson G, Hugosson J, and Pedersen KV: Transrectal ultrasound examination of the prostate: complications and acceptance by patients. Br J Urol71: 457459, 1993. 22. Walsh IK, Keane PF, and Herron B: Benign urethral polyps. Br J Urol 72: 937-938, 1993. 23. Van Poppel H, Vereecken R, De Geeter P, and Verduyn H: Hemospermia owing to utricular cyst: embryological summary and surgical review. J Urol129: 608609,1983. 24. Pryor JP: Hemospermia, in Whitfield HN, and Hendry WF (Eds): Textbook of Genitourinary Surgery, Edinburgh, Churchill Livingstone, 1985, pp 12081211. 25. Ogreid P, and Hatteland K: Cyst of the seminal vesicle associated with ipsilateral agenesis. Stand J Urol Nephrol 13: 113-116, 1989. 26. Heller E, and Whitesel JA: Seminal vesicle cysts. J Urol 90: 305-307, 1963. 27. Benson RC Jr, Clark WR, and Farrow GM: Carcinoma of the seminal vesicle. J Urol 132: 483485, 1984.
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28. Kawahara M, Matsuhashi M, Tajima M, Sawamura Y, Matsushima M, Shirai M, and Ando K: Primary carcinoma of the seminal vesicles. Diagnosis assisted by sonography. Urology 32: 269-272, 1988. 29. Geoghegan JG, and Bonavia I: Hemospermia as a presenting symptom of lymphoma. Br J Urol 66: 658, 1990. 30. Yada B: On the study of hemospermia. Acta Urol Jpn 9: 175-205, 1989. 31. Koment RW, and Poor PM: Infection by human cytomegalovirus associated with chronic hematospermia. Urology 22: 617-621, 1983. 32. Ashkar MF, and lssa II: Bilharzial hemospermia. J Egypt Med Assoc 18: 274, 1935. 33. Elem B, and Patil PS: Hemospermia: observations in an area of endemic bilharziasis. Br J Urol 60: 170-173, 1987. 34. Lembeli CM, and Venkataramaiah NR: Re: Schistosoma haematobium ova in semen. J Urol 125: 603, 1981. 35. Halim A, and Vaezzadeh K: Hydatid disease of the genitourinary tract. Br J Urol 52: 75-78, 1980. 36. Whyman MR, and Morris DL: Retrovesical hydatid causing hemospermia. Br J Urol 68: 100-101, 1991. 37. Craig SR: “3-in-l” nerve block complicated by hemospermia. Br J Clin Pratt 46: 80, 1992. 38. Close CF, Yeo WW, and Ramsay LE: The association between hemospermia and severe hypertension. Postgrad Med J 67: 157-158, 1991. 39. lversen PS: Hemospermia and hypertension. Ugeskr Laeger 149: 596, 1987. 40. Hamburger S, Styczynski M, O’Heame J, and German G: Hemospermia and hypertension: two case reports. J Kansas Med Sot 81: 459460, 1980. 41. Magid MA, and Hejtmancik JH: Hemospermia. J Urol 78: 82-88, 1957. 42. Littrup PJ, Lee F, McLeary RD, Wu D, Lee A, and Kumasaka GH: Transrectal US of the seminal vesicles and ejaculatory ducts: clinical correlation. Radiology 168: 625-628, 1988. 43. Lamesh RA: Recurrent hematuria and hematospermia due to prostatic telangiectasia in classic von Willebrand’s disease. Am J Med Sci 306: 35-36, 1993. 44. Smith GW, Griffith DP, and Pranke DW: Melanospermia: an unusual presentation of malignant melanoma. J Urol 110: 314-316, 1973. 45. Etherington RJ, Clements R, Griffiths GJ, and Peeling WB: Transrectal ultrasound in the investigation of hemospermia. Clin Radio1 41: 175-177, 1990. 46. Worischeck JH, and Parra RO: Chronic hematospermia: assessment by transrectal ultrasound. Urology 43: 515-520, 1994. 47. Maeda H, Toyooka N, Kinukawa T, Hattori R, and Furakawa T: Magnetic resonance images of hematospermia. Urology 41: 499-504, 1993. 48. Secaf E, Nuruddin RN, Hricak H, McClure RD, and Demas B: MR imaging of the seminal vesicles. AJR Am J Roentgen01 156: 989-994, 1991. 49. Kenney PJ, and Leeson MD: Congenital anomalies of the seminal vesicles: spectrum of computed tomographic findings. Radiology 149: 247-251, 1983. 50. Silverman PM, Dunnick NR, and Ford KK: Computed tomography of the normal seminal vesicles. Comput Radio1 9: 379-385, 1985. 51. Huggins C, and McDonald DF: Chronic hemospermia: its origin and treatment with estrogen. J Clin Endocrinol 5: 226-231, 1945.
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