What Causes Blood in the Semen (Haematospermia)? When Does It Matter?

Seeing blood in the semen during ejaculation is one of the findings that worries men most. Many who notice a red, pink or brown discolouration immediately suspect a serious illness. Yet this condition, known medically as haematospermia, is in most cases linked to a benign cause, particularly in younger men, and it frequently resolves on its own.

That said, further assessment is needed in some situations. This article explains the possible causes of haematospermia, which findings call for more detailed investigation, the steps by which assessment is carried out and how treatment is planned.

What is haematospermia?

Haematospermia is the presence of visible blood in the semen. Semen is a mixture of sperm produced in the testicles and secretions from the prostate, the seminal vesicles and other glands. A small bleed in any of these structures, or in the ducts through which semen passes, can change the colour of the semen.

The shade of the colour gives an idea of the timing of the bleed. A bright red colour usually suggests a recent bleed, whereas a brown or dark colour suggests older blood that has been sitting for some time.

What causes blood in the semen?

The causes that can lead to haematospermia span a wide range. The headings most often encountered in the clinic are as follows:

• Medical procedures: Prostate biopsy is among the most common causes. After a biopsy, blood in the semen can be seen for several weeks, sometimes longer, and this is expected. A similar picture can develop after vasectomy and some endoscopic procedures.
• Infection and inflammation: Infections of the prostate, seminal vesicles, epididymis and urinary tract, as well as sexually transmitted infections, can cause bleeding.
• Stones and cysts: Calcifications, stones and cysts forming within the prostate or seminal vesicles, and narrowing of the ejaculatory ducts, can predispose to bleeding.
• Prostate enlargement: In benign prostate enlargement, the increase in blood vessels on the surface of the prostate can lead to haematospermia, particularly at an older age.
• Sexual habits and trauma: Factors such as the first ejaculation after a long period of abstinence, intense sexual activity, a blow to the perineal area or prolonged cycling may play a part.
• Systemic conditions: Conditions such as uncontrolled high blood pressure, clotting disorders, the use of blood-thinning medicines and liver disease can make bleeding more likely.

In many patients, however, no clear cause is found despite assessment. This is referred to as idiopathic haematospermia and is common, particularly in younger men.

Is it usually benign?

Yes. Haematospermia that occurs once or briefly, particularly below the age of 40 and without any other accompanying complaint, is mostly benign. In this group the picture usually settles on its own within a few weeks.

The likelihood of blood in the semen being a sign of a serious illness such as prostate cancer is low. However, that likelihood increases with age, and greater care is needed in people with risk factors. Being "usually benign" therefore does not mean the finding should be ignored altogether; what matters is identifying who needs further investigation.

When is further investigation needed?

Current guidelines recommend that the scope of assessment in haematospermia be determined by the patient's age and accompanying findings. More detailed investigation comes into consideration in the following situations:

• Being aged 40 or over: In this age group, the scope of assessment is broadened to rule out conditions arising from the prostate.
• Recurrent or persistent bleeding: Haematospermia that continues for weeks or reappears at intervals calls for further investigation.
• Blood in the urine: Where haematospermia is accompanied by blood in the urine, the bladder and upper urinary tract also need to be assessed.
• Accompanying symptoms: Fever, burning on passing urine, groin or perineal pain, painful ejaculation, a weakening urinary stream, testicular swelling or unexplained weight loss.
• Risk factors: A family history of prostate cancer, a known clotting disorder or noticing a lump in the genital area.

How is the assessment carried out?

Assessment proceeds step by step, and not every test is needed in every patient:

• History: When the bleeding started, how many times it has been seen, its colour, any recent procedures, medicines in use, sexual history and accompanying complaints are all asked about. It is also important to distinguish whether the blood comes from the semen, the urine or the partner.
• Physical examination: The testicles, epididymides and external genitalia are examined, and a digital rectal examination is performed to assess the prostate. Measuring blood pressure is also part of the assessment.
• Urinalysis and culture: Infection and blood in the urine that is not visible to the eye are looked for. Where considered necessary, a semen culture and tests for sexually transmitted infections are requested.
• PSA: In men aged 40 and over, a PSA test comes into consideration after the benefits and limitations of the test have been discussed.
• Ultrasound and TRUS: Alongside kidney and bladder ultrasound, a transrectal ultrasound of the prostate (TRUS) is used to examine the prostate, seminal vesicles and ejaculatory ducts for stones, cysts or dilation.
• MRI: A multiparametric prostate MRI may be requested where bleeding persists or recurs, where other tests have not clarified the cause, or where prostate cancer is suspected.

In patients found to have blood in the urine, additional bladder investigations such as cystoscopy may also be planned. The scope of testing is determined individually for each patient according to age, history and examination findings.

Treatment approach

Treatment in haematospermia is directed at the underlying cause. In patients where no cause is found and who carry no risk factors, information and follow-up are often sufficient.

• Information and follow-up: In younger patients without risk factors, the benign nature of the picture is explained; the bleeding usually resolves on its own.
• Treating infection: Where tests demonstrate an infection, appropriate antibiotic treatment is given. Using medicines at random without evidence is not recommended.
• Correcting systemic causes: Blood pressure needs to be brought under control, and clotting disorders addressed together with the relevant specialist. Blood-thinning medicines, however, must never be stopped without consulting a doctor.
• Stones, cysts and narrowing: In selected patients, procedures such as opening a narrowed ejaculatory duct or endoscopic examination of the seminal vesicles may be considered.
• Other causes: Where prostate enlargement or rarer serious causes are identified, treatment is planned specifically for that diagnosis.

When should a doctor be consulted?

Consulting a urologist is advised in the following situations:

• If you are aged 40 or over and have noticed blood in your semen, even once
• If blood in the semen lasts longer than a few weeks or keeps recurring
• If you see blood in your urine or a change in its colour
• If it is accompanied by fever, burning on passing urine, painful ejaculation or groin pain
• If you notice swelling, hardness or a palpable lump in the testicle
• If you take blood-thinning medicines or have a known clotting problem
• If there is a family history of prostate cancer

Although seeing blood in the semen can be alarming at first, it is in most cases a benign condition that settles by itself. What matters is correctly identifying who needs further investigation, according to criteria such as age, recurrence, blood in the urine and accompanying symptoms. An assessment built on history, examination and stepwise testing both reduces unnecessary worry and ensures that rare serious causes are not overlooked. Assoc. Prof. Zülfü Sertkaya practises in urology and andrology in Istanbul; assessment and treatment planning in haematospermia are carried out with individual assessment and confidentiality.

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