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Background Hematospermia is defined as blood in the semen.

While often perceived as a symptom of little significance, blood in the ejaculate can cause great concern to the men who experience it. The condition is common, and many episodes go unnoticed therefore, the prevalence of hematospermia remains unknown. !n most patients with hematospermia, no further diagnostic workup is needed however, in some patients, hematospermia may be the first indicator of other urologic diseases. Hematospermia has been written about for centuries. Hippocrates, "alen, #are, $orgagni, and %ournier all commented on this condition. The first &merican report appeared in '()*, and %letcher,+', -eary,+., $arshall,+/, and "anabathi+*, have subse0uently published excellent contemporary reviews on the subject. The advent of newer imaging modalities has altered both the diagnosis and the treatment of hematospermia #athophysiology %or an understanding of the causes of hematospermia, a working knowledge of the relevant anatomy of the ejaculatory complex is useful. The seminal vesicles are androgen1dependent accessory organs that produce and store seminal fluid, which is essential to male fertility. The seminal vesicles are best studied ultrasonographically. 2ormal seminal vesicles are flat paired structures that lie cephalad to the prostate behind the bladder and have a bow1tie appearance on transverse imaging. They are symmetric, well1defined, saccular, elongated organs. !n its normal collapsed state, the center of the gland is homogenous, with areas of increased echogenicity corresponding to the folds of secretory epithelium. !n the distended state, the wall is visibly composed of . distinct layers. 3audally, the seminal vesicles diverge laterally. The dimensions of the seminal vesicles vary with age, but not with the ejaculatory state. 4pon transrectal ultrasonography 5T6478, the dimensions are estimated to be /9 : ; mm in length, '; : * mm in width, and '/.< : /.< m- in mean volume. The age of the patient and degree of prostate enlargement have been shown to cause variation in the si=e of the seminal vesicles. $6! findings may also help delineate the normal anatomy of the seminal vesicles. 4sing $6!, the signal intensity of the seminal vesicles can be compared with the tissues surrounding them 5ie, skeletal muscle, fat, urine8. The signal intensity on T'1weighted spin1echo images of normal seminal vesicles in men is similar to or slightly higher than that of skeletal muscles and is always greater than that of urine. >n T.1weighted images, the signal intensity varies. !n prepubertal boys and men older than <9 years 5androgen1 deprived males8, the signal intensity is generally lower than that of skeletal muscle or urine. 3onvolutions of the seminal vesicles are best observed on T.1weighted images or on T'1weighted images with the use of intravenous contrast agents.

The vasa deferentia act as conduits, carrying sperm between the epididymis and the ejaculatory ducts via the vasal ampullae. The vasal ampullae pass medially to the seminal vesicles and are best seen using transaxial T647 views. The seminal vesicles and vasal ampullae join together to form the ejaculatory duct. The ejaculatory duct travels through the prostate and enters the urethra at the level of the verumontanum. The junction between the seminal vesicle and the ejaculatory duct lies within the prostate and is difficult to see in a healthy unobstructed system. 7mall echodensities are fre0uently seen at the junction of the ejaculatory ducts and the verumontanum in the urethra. These areas provide useful landmarks and are thought to represent concretions within the periurethral glands surrounding the verumontanum. ?pidemiology %re0uency 4nited 7tates The true prevalence of hematospermia is unknown because most ejaculations occur intravaginally and hematospermia often remains unrecogni=ed. 6ecent data collected after T6471guided biopsy of the prostate suggest that up to /@./A of men undergoing @1'; cores develop postprocedure hematospermia. !ncreasing the number of cores did not significantly increase the fre0uency of hematospermia.+;, 7ex Hematospermia affects only males. &ge Hematospermia can occur in males of any age. !n younger men 5B *9 y8, hematospermia is uniformly benign. ?ven in older men, it is rarely associated with malignancy. History & good patient history that concentrates on trauma, infection, and bleeding disorders often helps to narrow the differential diagnoses associated with hematospermia. $ost men with hematospermia are young 5mean age, B *9 y8 and have symptoms ranging in duration from '1.* months. $ost patients have more than one episode, occurring over weeks to months. While no uniformly accepted definition of chronic hematospermia has been determined, blood in the ejaculate that persists for more than '9 ejaculations re0uires further evaluation. While some authorities use duration 5ie, months8 as a guideline, the discrepancy in the fre0uency of ejaculations among men renders this approach less reliable. #hysical The physical examination should include measuring the patientCs blood pressure because severe hypertension is associated with hematospermia. This association is well recogni=ed however, the exact mechanism by which it occurs is unclear. !t may have a similar basis to the association of hypertension with epistaxis 5nosebleeds8.

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 to rule out any induration or nodularity. &ny nodularity in the absence of prior vasal surgery 5including vasectomy8 should raise concern for a tuberculous infection of the vasa. &lternatively, nodules within the vas rarely represent extension of prostatic or bladder malignancies. 4pon digital rectal examination 5D6?8, special attention should be given to the seminal vesicles and the presence of any midline masses. The seminal vesicles are routinely nonpalpable structures. !f they are palpable, this generally indicates significant underlying pathology. !n older men 5E;9 y8, specific attention should also be given to the prostate because hematospermia is occasionally a harbinger of prostate cancer. 3auses Hematospermia is usually associated with inflammatory conditions of the seminal vesicles or prostate. The condition is often self1limited and resolves within '1. months. !f hematospermia persists beyond . months, further workup is recommended to determine the cause. !n approximately half the cases, the etiology is declared idiopathic. However, this may reflect an incomplete evaluation. 3onditions of the prostate -esions of the prostate account for many cases of hematospermia. The most common etiology is prostate biopsy, which produces self1limited hematospermia that resolves within approximately ' month. !n one case series, prostatitis was cited as the etiology in /9A of the patients. >ther authors have recogni=ed prostate cancer as an etiologic factor. $alignancies account for .A of cases. !n a long1term follow1up study of ';9 patients with hematospermia, only @ patients eventually developed prostate carcinoma, and none had prostate carcinoma diagnosed at the time of the initial evaluation. However, a recent study by Han et al reported a significantly increased risk of prostate cancer among men with hematospermia. >f '/) men with hematospermia, ') 5'/.<A8 were diagnosed with prostate cancer. !n the overall cohort of .@,'.@ patients, the prostate cancer detection rate was @.;A. >n logistic regression analysis, the presence of hematospermia was a significant predictor of prostate cancer diagnosis.+@, This is still a controversial area of investigation. $ore recently, #rando 5.99(8 reported on a series of (@ men with hemospermia and found prostate cancer in only one patient.+<, Hematospermia can also be caused by prostatic telangiectasia and varices. !n rare cases, a patient with hematospermia may be diagnosed with prostatic varices only after cystoscopic examination while experiencing an erection. !n order to diagnose this condition, flexible 5preferably8 or rigid cystoscopy is conducted after pharmacological induction of an erection. #rostatitis is often thought to cause hematospermia, although no specific association has been reported. 4pon signs and symptoms of acute bacterial prostatitis, specific treatment is indicated. !f symptoms of chronic pelvic pain prostatitis syndrome are present, urine culture and then culture of expressed prostatic secretions should be performed. Hematospermia is not a recogni=ed symptom of chronic prostatitis syndrome.

!n a study of ;. patients with hematospermia, ?therington et al found a significant number of patients with prostatic calculi.+(, &nother 5.99;8 publication reported on cystic dilation of the prostatic utricle in association with hematospermia. %uruya and Fato reported on /9 of '/( men with hematospermia who had a midline cyst of the prostate. 2ineteen men underwent transperineal biopsy hemorrhagic fluid was confirmed in '/ of the men. %our of the men were cured with transurethral unroofing.+), With the advent of T6471guided prostate biopsy for the diagnosis of prostate cancer, a new etiology of hematospermia has emerged. $any centers have reviewed their experience with this complication. The rate of hematospermia following transrectal biopsy of the prostate has varied from )1 *;A. !n one study, .;A of patients who underwent T647 biopsy had concomitant hematospermia and hematuria after the procedure. !n .99*, Berger et al reported on ;);< biopsies performed in */9/ men. This group found that hematospermia occurred after approximately /@A of the biopsies. They concluded that, in this situation, the hematospermia is generally self1limited and re0uires no specific therapy.+;, Transurethral resection of the prostate is also associated with subse0uent hematospermia. & study by 7hen et al described (9 consecutive men who underwent transurethral prostate resection and found that hematospermia developed in ..;A of the men.+'9, 7ome authors have recommended administering finasteride beginning . weeks prior to T647 biopsy of the prostate to reduce the risk of postprocedure hematuria. While no studies have specifically examined the impact of finasteride on the occurrence of hematospermia, this condition may be improved with the use of this medication. Brachytherapy as treatment for prostate cancer involves inserting radioactive seeds directly into the prostate. This procedure has been shown to cause hematospermia in up to '<A of patients who undergo this treatment.+'', 3onditions of the urethra 4rethritis has long been recogni=ed as a cause of hematospermia, especially in younger men. >ther urethral lesions leading to hematospermia include cysts, polyps, condylomata, and strictures. Benign urethral polyps can occur following failure of the invagination process of the prostatic glandular epithelium. !n one case series, .9A of patients with urethral polyps had hematospermia as their presenting symptom. !n another study, urethritis, condylomata, and stricture disease represented the cause of hematospermia in <A, '.;A, and '.;A of the patients, respectively. 7eminal vesicle lesions $any authors have cited congenital and ac0uired seminal vesicle cysts as a cause of hematospermia. 3ongenital cysts result from an error in embryological development and are associated with ipsilateral renal agenesis andGor ipsilateral congenital absence of the vas deferens. &c0uired seminal vesicle cysts generally result from infectious processes, and malignancies of the seminal vesicles are a rare cause of hematospermia. !n one review of /) patients with primary carcinoma of the seminal vesicle, only @ patients 5'@A8 had hematospermia. $ore recently, amyloidosis of the seminal vesicles has been described to be related to hematospermia.+'., %ifty1six men with hematospermia were evaluated with $6!, and

obvious intravesicular hemorrhage was associated with hyperintense signal 5brighter8 of the seminal vesicles on $6!. &fter resolution of the bleeding, the signal returned to a hypointense state 5lighter8 on $6!. Twelve of these patients underwent transperineal biopsy * were found to have seminal vesicle amyloidosis. !n all cases, hematospermia resolved with conservative intervention. The most recent data suggest that seminal vesicle and ejaculatory duct cysts or hemorrhagic lesions account for most identifiable causes of hemospermia. %ifty1two of (@ men in a recent study were found to have lesions in association with hemospermia. >f these men, ;' had some type of seminal vesicle, ejaculatory duct, or prostatic benign or hemorrhagic lesion. >nly one case of prostate cancer was identified.+<, !nfections !nfections and inflammatory disorders account for *9A of cases. !nfectious causes of hematospermia include tuberculosis 5TB8, H!H infection, and cytomegalovirus infection. Iu and colleagues found that ''A of a cohort of @; patients with genitourinary TB had hematospermia during their disease.+'/, & recent review of '@ men with hematospermia who presented to a sexually transmitted infection clinic found pathogens in '. of the men. These included urine, genitourinary, or serum cultures or titers positive for herpes simplex virus in ;, 3hlamydia trachomatis in *, ?nterococcus faecalis in ., and 4reaplasma urealyticum in one. 3ulture1specific antibiotics were administered, and hematospermia resolved in all the patients.+'*, 7everal authors have reported schistosomiasis as a cause of hematospermia. &lthough these patients often have extensive bladder involvement, 7chistosoma hematobium ova are only occasionally found in the ejaculate. Hydatid disease, a parasitic infection caused by the ?chinococcus worm, has also been associated with hematospermia. Trauma Trauma has been cited as a cause of hematospermia in several case reports. 7uch case reports include hematospermia occurring following hemorrhoidal sclerosing injection, urethral self1instrumentation, and testicular and perineal blunt trauma. Hematospermia following transrectal prostate needle biopsy should also be included in this category. &pproximately .A of cases are believed to result from trauma other than that related to recent prostate biopsy. 7ystemic disorders 7ystemic disorders that are associated with hematospermia include hypertension, chronic liver disease, amyloidosis, lymphoma, and bleeding diatheses 5von Willebrand disease8. !n one case1controlled study of patients undergoing hypertension therapy, the prevalence of hematospermia was no higher than in the general population however, hematospermia resolved in several patients when their hypertension was controlled. 6isk factors for hematospermia in patients who are hypertensive include severe uncontrolled hypertension, elevated serum creatinine levels, severe proteinuria, and renovascular disease. Differential Diagnoses &bdominal Trauma, Blunt Tuberculosis Tuberculosis of the "enitourinary 7ystem

-aboratory 7tudies 4rinalysis and culture 4rinalysis and culture may prove helpful because urogenital infections may be associated with hematospermia. 4nfortunately, the rate of positive culture results is low, varying from @1.)A. Because this test is of low cost and a positive result suggests an etiology, urine culture is recommended in all patients who present with hematospermia. !f the history suggests exposure to TB, urine culture for acid1fast bacilli may prove helpful because TB is a cause of hematospermia in as many as '/A of patients in some series. !n younger men, urethritis should be considered in the differential diagnoses, and urethral swabs should be obtained and examined to help exclude nonspecific and gonococcal urethritis. Blood in the urine mandates a more extensive evaluation of the genitourinary tract. &t the authorsC institution, patients presenting with hematuria undergo the following testsJ urinalysis, urine culture, urine cytology, 3T scan of the abdomen and pelvis with contrast, and cystoscopy. 7emen analysis and culture The role of semen analysis and culture remains unclear. While advocated by some authors, the significance of a positive culture result remains uncertain because this may simply represent urethral contamination. 7emen analysis may prove helpful in the differentiation of true hematospermia from other causes of ejaculate discoloration. 7mith et al reported . cases of melanospermia as the presenting feature of malignant melanoma.+';, $elanin produces a dark brown or black discoloration of semen rather than red or pink, which occurs with hematospermia. !f necessary, the two can be differentiated based on chromatography findings. 2ormal semen should appear as a coagulum that li0uifies over a ;1 to .;1minute period. >therwise, laboratory analyses should be limited to an evaluation for bleeding disorders. Blood work #rostate1specific antigen analysis is recommended in all men older than ;9 years, &frican &merican men, and men older than *9 years with a family history of prostate cancer. Hematospermia may be a harbinger of prostate cancer. 3oagulation studies are recommended in men of all ages with persistent hematospermia 5E. mo8 because this condition is associated with coagulopathies. $edical 3are The primary goal in the management of hematospermia is to allay the anxiety of the frightened patient. Hematospermia is rarely associated with significant pathology, especially in younger men. The / factors that dictate the extent of the evaluation and treatment include 5'8 patient age, 5.8 the duration and recurrence of the hematospermia, and 5/8 the presence of any associated hematuria. $ost malignancies associated with hematospermia occur in patients older than *9 years. 3hronic hematospermia warrants more aggressive intervention to identify an etiologic factor. !n younger men with nonpersistent hematospermia, only a D6? 5along with a check of vital signs8 is re0uired as part of a careful physical examination. !n older men 5E;9 y8

with nonpersistent hematospermia without concomitant hematuria upon urinalysis, a basic evaluation consists of a D6? and a prostate1specific antigen measurement. &ll patients with concomitant hematuria need an evaluation of their upper 5with intravenous pyelography, renal ultrasonography, or spiral 3T scan8 and lower tracts 5with cystoscopy8. #ersistent hematospermia 5E. mo without defined etiology8 warrants a full workup as described in Workup. 4rogenital infections re0uire appropriate antibiotic therapy, which normally resolves the problem. !n all men, enterobacteria 5especially ?scherichia coli8 should be covered. !n younger men, concomitant therapy for chlamydial infections should also be used. & fluoro0uinolone should ade0uately treat both organisms. !f the patient is allergic to fluoro0uinolones or cannot afford this class of drugs, a combination of trimethoprimGsulfamethoxa=ole and doxycycline is often successful. & .1week course is usually sufficient. 3oncomitant inflammation may be treated with ibuprofen or other nonsteroidal anti1inflammatory medications. 4rethral or prostatic varices are best fulgurated, while cysts, of either the seminal vesicles or prostatic urethra, can be aspirated transrectally. %use and colleagues injected coagulant substances into dilatated seminal vesicles under T647 guidance in < patients with hematospermia. The hematospermia was transiently resolved by this maneuver for a maximum duration of / months, at which time the condition recurred.+'(, Therefore, currently, no evidence suggests that the injection of any substance, coagulant or sclerosant, has any role in the management of hematospermia. Bleeding diatheses or other systemic disorders should be managed in the appropriate manner. !n men with coexisting bladder outlet obstruction, a ;1alpha reductase inhibitor may be used. 2o rationale currently exists for the use of oral agents, such as estrogens or corticotrophins, which have been used in the past. 7urgical 3are #atients in whom bleeding prostatic variceal veins are suggested as the cause of hematospermia are candidates for fulguration. &fter infectious causes have been excluded in cases of persistent hematospermia, cystourethroscopy is performed. !f large friable prostatic veins are discovered and examination findings are otherwise normal, fulguration with a Bugbee or loop electrode can be performed. #rior to fulguration, a biopsy should be performed on any suggestive lesions. $ore recently, a techni0ue of endoscopy of the ejaculatory ducts and seminal vesicles has been described.+'), This techni0ue involves using a semirigid ureteroscope to cannulate the ejaculatory duct and allows the surgeon to examine the duct, seminal vesicle, and ampulla of the vas. However, the author reserves this techni0ue for only the most refractory cases of hemospermia that cause significant physiologic 5urinary retention or persistent hematuria8 or psychological 5avoidance of ejaculation8 trauma. #rognosis Hematospermia is usually self1limited however, when hematospermia is an indicator of underlying urologic disease, the prognosis depends on the underlying disease.

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