Blood in Semen (Hematospermia): Causes, Evaluation, and When to Worry

Blood in semen is not normal but is usually benign and self-limited. It warrants evaluation to rule out significant pathology.

Common Causes

• Prostatitis (acute/chronic) — most common cause in men <40; inflammation → fragile vessels.
• Seminal vesicle cysts / calculi — can rupture/bleed.
• Epididymitis/orchitis — inflammation of epididymis/testis.
• Trauma: Vigorous sex, masturbation, perineal injury, bike riding.
• Iatrogenic: Post-prostate biopsy (up to 80%), TURP, vasectomy, cystoscopy.
• STIs: Chlamydia, gonorrhea, HSV — urethritis/prostatitis.
• BPH: Vascular fragility in enlarged prostate.

Less Common but Serious

• Prostate cancer (rarely presents as isolated hematospermia; usually elevated PSA, abnormal DRE).
• Testicular cancer.
• Bleeding disorders, anticoagulants.
• Vascular malformations (AVM).
• Tuberculosis, schistosomiasis (endemic areas).

Evaluation

1. History: Duration, frequency, volume, pain, urinary symptoms, STI risk, procedures, meds.
2. Exam: DRE (prostate size, tenderness, nodules), testicular, inguinal nodes.
3. Urinalysis, urine culture, STI NAATs.
4. PSA (if >40 or risk factors) — interpret cautiously post-ejaculation/procedure.
5. Imaging: TRUS (transrectal ultrasound) if persistent >1 month, >40 yo, risk factors.
6. Cystoscopy if urethral source suspected.

Management

• Reassurance + observation if <40, single episode, normal exam/labs — resolves in weeks.
• Antibiotics for prostatitis/STI (fluoroquinolone or doxycycline × 2–4 wks).
• 5-ARI (finasteride) or alpha-blocker if BPH-related.
• Treat underlying cause.

When to See a Urologist

• Age >40
• Recurrent/persistent >1 month
• Associated pain, urinary symptoms, weight loss
• Abnormal DRE or elevated PSA
• On anticoagulants/bleeding disorder

Most hematospermia is benign. But never ignore it — especially after 40.