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Indian J Surg | December 2005 | Volume 67 | Issue 6
302
302 CMYK
Review ArticleReview Article
Review ArticleReview Article
Review Article
The sanguineous sperm (hemospermia)—The sanguineous sperm (hemospermia)—
The sanguineous sperm (hemospermia)—The sanguineous sperm (hemospermia)—
The sanguineous sperm (hemospermia)—
current appraisal and reviewcurrent appraisal and review
current appraisal and reviewcurrent appraisal and review
current appraisal and review
Iqbal Singh
Division of Urology, Department of Surgery, University College of Medical Sciences (University of Delhi) & G.T.B Hospital, F-14
South Extension Part-2, New Delhi-110049, India
For correspondence:
Iqbal Singh, Division of Urology, Department of Surgery, University College of Medical Sciences (University of Delhi) & G.T.B
Hospital, F-14 South Extension Part-2, New Delhi-110049, India. E-mail: iqbalsinghp@yahoo.co.uk
ABSTRACT
Aims: Hemospermia is an infrequently discussed urological problem. Most health care providers including
general surgeons and physicians are unfamiliar with this disorder, its etiology & management. We
undertook the present review to ascertain the magnitude of this problem and to device a working
algorithm to help the clinician in approaching a case of hematospermia. The symptoms, differential
diagnosis and management have been discussed. Materials and Methods: An Internet search was
made over the ‘Pubmed’ for indexed publications in the English literature using the keywords
hematospermia; hemospermia and bloody urethral discharge. Results: The search yielded about 75
indexed publications. These were reviewed and analyzed to determine the various etiological factors,
differential diagnosis and their management. We have suggested a clinical working algorithm and a
protocol to deal with cases of hemospermia. Conclusions: Hemospermia is not an uncommon urological
disorder. The problem is often idiopathic, transient and self-limiting in more than half the cases.
Polysymptomatic persistent hemospermia especially in the elderly may herald a more serious underlying
problem that should be investigated thoroughly to rule out malignancy. While not all cases merit an
extensive workup, selected cases of recurrent, symptomatic hemospermia associated with other
abnormalities may be analyzed in greater detail. The stepwise clinical working algorithm suggested
and devised by us on the basis of published cases will assist the treating surgeon/urologist in the
evaluation of such suspected cases of hemospermia.
Key words: Hematospermia, hemospermia, bloody urethral discharge
How to cite this article:
Singh I. The sanguineous sperm (hemospermia)—current appraisal and review. Indian J Surg 2005;67:302-7.
INTRODUCTION
Hemospermia or bloody seminal discharge is
an uncommon clinical entity. Though it is con-
sidered to be usually due to prostatitis and
generally runs a benign course resolving spon-
taneously most of the time, it often invokes
considerable anxiety and is frightening for the
patient. Though the most common cause is
infection or inflammation of the prostate, ure-
thra and the seminal tract, the older patients
with a persistent hemospermia need to be eval-
uated. The concern and apprehension in the
mind of the physician also stems from the pos-
sibility that an individual may be harboring malignan-
cy or a serious underlying abnormality. Many surgeons
& physicians are unfamiliar with this disorder and this
forms the basis for our current review of hematosper-
mia. We have reviewed the various etiological factors,
and discussed their clinical presentation, differential
diagnosis, diagnostic modalities and the current man-
agement protocol so as to familiarize the clinician when
dealing with such cases.
Definition and etiology
The international nomenclature of human semen pa-
rameters defines hemospermia (HS) or hematospermia
as the presence of fresh or altered blood in the ejacu-
late derived from pathology of accessory sexual glands,
urethra or the bladder; which is related to emission
and ejaculation, associated with infertility, hematuria,
Paper Received: Sepember, 2005. Paper Accepted: December,
2005. Source of Support: Nil.
Indian J Surg | December 2005 | Volume 67 | Issue 6
303
CMYK303
lower urinary tract obstructive symptoms, vascular
abnormalities, ductal obstruction, cysts, neoplasms and
systemic iatrogenic factors. HS still remains an infre-
quently discussed urological problem that is often rel-
egated to the end of most textbooks of urology. Though
historically HS was thought to be associated with al-
tered sexual behavior in the form of overindulgence
or prolonged abstinence and inhibition, it is now be-
lieved to be intermittent, benign and self-limiting in a
majority.[1] According to Perez JR et al even a protract-
ed phase of daily ejaculations via masturbation may
cause hematospermia, probably owing to stress of the
vasculature of the ejaculatory system.[2] The overall lack
of awareness and concern by the urologist/clinician
stems from a common notion that this is generally a
benign self-limiting problem,[3] though this may not
be always correct. It is important that the urologist
approach such patients with adequate concern and is
aware of the underlying conditions, especially malig-
nancy. [Table 1] shows a tabulated list of etiological
factors associated with HS. These may be congenital,
inflammatory, neoplastic, or related to iatrogenic trau-
ma. The commonest cause of HS is idiopathic in more
than 70% of the cases.[4] About 0.5% of patients with
cancer prostate may present with HS as a sentinel
symptom.[3] Iatrogenic trauma leading to HS is most
commonly seen with transrectal ultrasound guided
prostate biopsy and according to one recent large study
of 5957 biopsies performed in 4303 clinically healthy
men over a ten year period HS occurred as minor com-
plication in 36.3% of the subjects.[5] [Table 2] depicts a
summary of reported series and case reports of hemat-
ospermia showing their salient features, etiological,
diagnostic factors and their outcome. One of largest
series of HS reported by Leary et al[6] comprised 200
men in the 20-74 year age group, with 29% having
recurrent HS with a 5-23 year follow up period with
4% developing prostate cancer eight years following
the initial evaluation.
Clinical features & presentation
Hemospermia may be mono-symptomatic and prima-
ry or it may be secondary and present as a poly-symp-
tomatic disorder in association with other symptoms
depending on the underlying etiology. Other diverse
associated symptoms include pelvic/perineal pain, or-
gasmalgia (pain at the time of orgasm),[7] persistent
dysuria, hematuria, urinary tract infection and infer-
tility (ejaculatory duct obstruction/azoospermia / oli-
gozoospermia).[8] One must also inquire in to the his-
tory whether HS is acute or chronic and whether it is
mono or polysymptomatic. A history of post ejacula-
tory persistent painless hematuria is strongly sugges-
tive of prostatic/urethral polyps.[9,10] History of perine-
al/pelvic pain/discomfort should lead one to the sus-
picion of SV/ED cysts/calculi associated infection. His-
tory of HS associated with infertility, painful ejacula-
tion, and perineal, testicular or scrotal pain should be
carefully evaluated for possible ejaculatory duct ob-
struction (EDO).[11] The blood pressure should be re-
corded in all cases to rule out hypertension as a cause
of hemospermia (at least according to one study hy-
pertension was detected in 7.3 % of the patients pre-
senting with hemospermia).[12] Massive hemospermia
or post ejaculatory gross hemospermia is rarely encoun-
tered, the most likely causes include abnormal post
urethral vessels or posterior urethral or prostatic api-
cal varicosities, which may also lead to hematuria,
passage of clots and urinary retention.
Diagnosis
The initial approach to a patient with HS should in-
clude a detailed history and clinical evaluation includ-
ing a digital rectal evaluation (DRE). DRE may help in
detection of palpable SV cysts and prostate abnormal-
ities. It is important to be aware at this stage whether
the HS is primary or secondary. Mono-symptomatic
or primary HS is more common, often transient, idio-
pathic in origin and is generally not associated with
significant urological disease.[12,13] Never the less when-
ever a man over forty years presents with hemosper-
mia, prostate cancer screening should be vigilantly
performed since hemospermia may be associated with
a higher risk of prostate cancer.[3] A careful seminal
cytology/seminogram should be done to differentiate
clear HS from hemo-pyospermia in order to ascertain
the underlying pathology.[14,15] The next step should
be to perform urine cytology, in case clusters of co-
lumnar epithelial cells are found one must consider
benign prostatic epithelial polyps in the differential
diagnosis and in case cells with malignant cytology
found one must carry a careful diligent search for pro-
Table 1: Simplified classification of the salient
etiological factors leading to hemospermia
Congenital Prostatic urethral or adenomatous polyps,
papillary prostatic urethral adenomas,
hemangiomas, telengiectasia, vascular
abnormalities, mullerian duct (utricle) cysts, and
seminal vesicle cysts. (Children and pre-pubertal)
Inflammatory Urethroprostatitis or epididymo-orchitis; seminal
vesiculitis; calculi of the SV & ED apparatus,
chronic prostatitis, chronic nonbacterial
prostatitis (chlamydia trachomatis), viral urethral
condylomas, SV amyloidosis, malakoplakia of
prostate and SV,genitourinary tuberculosis &
schistosomiasis (adolescents)
Neoplastic Cancer and sarcoma of prostate, cancer seminal
vesicle, SV adenomyosis, testicular tumors,
metastasis to seminal vesicles (elderly)
Iatrogenic Post ESWLTM lower ureteric calculi, post prostate
biopsy, post HIFU/TURP, post prostate
brachytherapy, post vasectomy.
Medical Hypertension
SV/ED: Seminal vesicles, ejaculatory duct; ESWLTM: Extra-corporeal
shockwave lithotripsy; HIFU: High intensity focused ultrasound.
The sanguineous sperm (hemospermia)–current appraisal and review
Indian J Surg | December 2005 | Volume 67 | Issue 6
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Singh I
Table 2: Table depicting some important publishedreviews/reports on hemospermia
No Author Nos Presentation Diagnosis Therapy
1 Han M, 2004 19 HS (13.7%) Ca Prostate -
2 Yagci C, 2004 56 HS TRUS-Abnormalities-51( 95%) Prostate calcifications
(23), ED calculi (21), dilated ED/SV (18)/(21), ED cyst(6),
prostatitis (6), BPH (18)
3 Singh I, 2003 1 HS + loin pain Ejaculatory duct calculus Endoscopic removal. Cured
4 Frenandez, 2003 1 HS + supra-pubic pain Localised amyloidosis Diagnosed by TRUS Bx -
5 Tan Mo, 2003 2 HS, hematuria, LUTS Papillary adenoma -prostatic urethra- Endoscopic fulguration. Cured
6 Kamura, 2003 10 HS, hematuria, voiding difficulty Bullous lesion of prostaticUrethra. Endoscopic extirpation. Cured
7 Chen, 2002 42 HS + vague pelvic pain Chronic seminal vesiculitis. TRUS-SV puncture + antibiotic instill. (91% cured)
9 Rodriguez, 2002 59/290(21%) - Post TRUS Bx hemospermia AntibioticsCured
10 Calahorra, 2001 1 HS+ oligozoospermia Giant SV cyst with ipsilateral renal agenesis S.vesiculectomyCured
11 Yanagisawa, 2002 1 HS Squamous carcinoma in acquired SV cyst S.vesiculectomyCured
10 Ameur, 2002 7 H S Urethroprostatitis, epididymo-orchitis & cancer prostate Antibiotics and orchidectomy
12 Kochakarn, 2002 68 HS with a 5 year follow up Prostatitis (29.7%), TB (4.4%) STD (5.8%), According to cause
idiopathic (61%),hypertension (7.3%)
13 Portillo FJ, 2001 9 HS- gross (2), microscopic (7) Post ESWL for lower ureteral calculi Self limiting in 12 weeks
14 Galan M, 2001 136/303 (44.9%) HS Post Prostate Bx Self limiting in one week
15 Mi ZG, 2001 131 HS occurred in 51% post resect. Posterior urethral adenoma TU resection.Cured
16 Bermudez AM, 2002 1 HS + Recc epididy-orchitis Cystic dilatation of the prostatic utricle with right Transperitoneal S. vesiculectomy Cured
renal agenesis
17 Lu CH, 2000 40 HS evaluated by TRUS Idiopathic (17%), 83%-ED/ MD cysts, SV dilatation + stones, -
BPH, pre-prostatic vein engorgement, prostatic stones)
18 Lencioni R,1999 90 HS evaluated by MRI Blood in SV/ED(23), Dilated SV/ED (30), Cystic SV/ ED (14), -
SV calculi (7)
19 Furuya S, 1999 21 HS evaluated by TRUS+SV SV dilated(1),cyst(1), MD cyst (2), Amyloidosis(1), ectopic TRUS guided SV puncture/aspiration
puncture prostatic urethral tissue(4)
20 Toyota, 1998 1 HS Pelvic AV-malformation EmbolisationCured
21 Vilana R 1997 2/9 HS Schistosomiasis -
22 Cho Ir,1997 17 HS evaluated by MRI Calculi + cysts in SV/ED/MD -
23 Nicolai M, 1996 80 HS Idiopathic (50%)/Infect 20%,periurethral/ED calculi-60%, -
Dilated SV (31.4%), MD cysts (8.6%)
24 Segal As, 1996 107 HS Benign urethral neoplasms: viral papillomas (67.3%), polyps TU resection, electrocoagulation, partial
(22.4%), angiomas (10.3%). urethral resection. Cured
25 Gattoni, 1996 85 HS Periurethral calcification-41.3%, prostatitis 24.7%, Seminal -
vesiculitis-11.7%,Prostatic Ca-3.5%,Idiopathic-12.9%
26 Dik P, 1996 34 HS+ scrotal pain+ dysuria,infertility Medial prostatic cyst TU cyst marsupialisationCured
27 Corachan M, 1996 10 HS + prostatitis like symptoms Schistosomiasis diagnosed by ultrasound & parasitology -
28 Amano T, 1994 46 HS Prostatic stones+ SV dilatation & calculi,BPH Prostatitis -
in 73.9% diagnosed by TRUS
29 Schall MD, 1992 26 HS, hypospermia, oligospermia, [Mullerian cysts(4), wolffian cysts(3), prostate ca(1)], EDO, -
+ painful ejaculation seminal vesiculitis+ non cystic SV pathology (7) diagnosed
by HR-MRI- ER coil
30 Sampalmieri G, 1992 60 Isolated HS -20%Assoc HS-35% Urethro-prostatitis, SV dilatation, Ca prostate, T B -
31 Sato N, 1990 61 HS + Hematuria+ urethrorrhagia Prostatic urethral papillary adenoma TU fulguration+ Recurrence in 6.7%
32 Fernandez JM, 1990 29 Polysymptomatic HS Urethral -prostate-vesicular inflammation-55%, idiopathic-24%, -
SV cyst(1),Ca (2)
33 Chou K, 1999 4 HS+ Hematuria Prostatic urethral adenomatous polyp -
34 Tzai TS, 1989 38 HS Idiopathic-29%,[prostatitis(20)SV infection (3), BPH(3), -
SV stone(1), prostatic calculi(3)]-71% on TRUS
35 Leifert S, 1985 1 HS+ urethrorrhagia Urethral ectopic prostatic tissue TU fulgurationCured
36 Baroudy AC, 1984 25 HS + hematuria Prostatic urethral papillary adenoma TU fulgurationCured
37 Yu HH, 1977 65 Isolated HS, TB, Scrotal pain Idiopathic-57%, TB-11%, Epididymal nodule-28% -
38 Leary,1974 200 HS Ca prostate-4%, 29% recurrent HS -
HS-Hemospermia, SV-Seminal vesicle, ED-Ejaculatory duct, MD- mullerian duct, TRUS-Transrectal ultrasound, HR-MRI-ER- High resolution magnetic resonance imaging with endorectal coil, TU-Transurethral, Bx-Biopsy, TB-
Tuberculosis.
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static neoplasm or malignancy with special immu-
noperoxidase stains for evidence of prostatic epitheli-
al cell origin.[16-18] In case the cytology is negative it is
appropriate to carry out urine/semen culture analysis
to rule out an infectious etiology. If sterile pyuria is
encountered one must rule out chronic non-bacterial
prostatitis, prostatodynia and rare infections such as
genitourinary tuberculosis, schistosomiasis, chlamy-
dia trachomatis, cytomegalovirus infestation, localized
amyloidosis of the seminal vesicles and or HIV.[19-23]
Radiographic imaging by transrectal ultrasound
(TRUS), vasography and or MRI is indicated where no
apparent cause can be ascertained and the suspicion
of a structural abnormality of the seminal apparatus
exists. Initially it is best to proceed with TRUS[24] which
can demonstrate any structural abnormality in the sem-
inal vesicle (SV), vas ampulla, ejaculatory duct (ED)
such as dilatation, mullerian or utricular cyst, and ED
or SV calcification, congenital mullerian (utricle) cysts,
cysts/calculi of the SV, ED and the prostate.[25-27] Cystic
changes in the SV and ED apparatus contribute to HS
via certain allergic or inflammatory reactions.[26] In case
multiple cystic masses are found in association with
prostatic cysts it is important to delineate them with
more accurate and precise modalities such as CECT or
MRI to plan their management.[11,25,28,29] Normal SV are
depicted on T2weighted images as a mixture of high
and low-signal intensity (convolution of tubules with
a diameter of < than 0.5 cm).[29] Recently MRI with a
body coil and an endorectal coil using fast spin-echo
techniques have been also employed to evaluate such
cysts. SV hemorrhage, chronic infection and fibrosis
can be detected by T1/2 weighted images of MRI with a
high degree of accuracy.[30,31] In acute hematospermia
both TRUS and MRI may appear normal. In chronic
hemospermia TRUS may reveal dilated SV with or
without increased echogenecity due to hemorrhage
within the SV, in such cases an MRI may show in-
creased signal intensity on T1 weighted images which
may become slightly decreased in signal on T2 weight-
ed images. Other findings such as ejaculatory/mulleri-
an duct/prostatic cysts, calculi and urethral polyps may
also be ascertained.
In cases of HS with infertility due to suspected ejacu-
latory duct occlusion the diagnosis can be confirmed
by percutaneous seminal-vasography combined with
methylene blue solution for radiological and direct
cystoscopic visualization.[11] Percutaneous vasography
is an efficient method to diagnose diseases of the sem-
inal vesical and ductal system such as seminal vesicu-
litis, seminal vesicle cysts, chronic prostatitis and can-
cer prostate all of which may be associated with he-
mospermia.[32] If all attempts fail to clinch the diagno-
sis cystourethroscopy should be considered[33] and
particular concentration should be directed towards
the prostatic urethra and the area around verumonta-
num for any polyps or ectopic prostatic tissue as a cause
of persistent painless hematuria and hemospermia.[9,10]
[Table 3] shows a stepwise clinical diagnostic algorithm
that has been suggested by us to facilitate the work up
of case of hemospermia and or hemopyospermia.
Management
Treatment should be tailored to the cause. Primary or
isolated hemospermia is often self-limiting. Infection
and inflammatory pathology of the lower seminal tract,
which is often the most frequent underlying patholo-
gy, should be treated with appropriate antibiotics.[34 ]
Where radiological imaging reveals structural abnor-
mality surgical correction should be performed espe-
cially in cases of persistent and or recurrent hemos-
permia. Cysts of the ejaculatory duct and seminal ves-
icle apparatus have been traditionally treated by
transurethral cyst deroofing especially when associat-
ed with calculi or ejaculatory duct obstruction.[5] Al-
ternatively solitary/recurrent SV cysts can be safely
managed by transperineal or transrectal aspiration and
or ultrasound guided sclerotherapy.[33,35] TRUS guided
aspiration & antibiotic injection of the dilated SV+ED
apparatus may be diagnostic[36] as well as therapeu-
tic.[37] TRUS guided continuous trans-catheter instil-
lation of antibiotics has been successfully deployed
for the therapy of chronic seminal infections with a
cure rate of over 90%. Although simple cyst aspira-
tion is useful and a minimally invasive option to de-
termine and treat the bleeding site responsible for HS[38]
it necessitates a longer follow up and is often associat-
ed with a 50% echo proven relapse rate.[8] Besides sim-
ple cyst puncture, endoscopic section or marsupiali-
sation can also be considered for large or complicated
cysts. For a reliable cyst transurethral de-roofing it is
essential to perform the procedure under TRUS guid-
ance and preoperative cyst injection with a colored
dye such as methylene blue.[37] With current endoscop-
ic procedures the long-term cure rate (for mullerian or
seminal cysts) approaches 82%.[8] Vesiculectomy or
partial vesiculectomy may give excellent results in
cases of larger and or recurrent SV cysts. Ejaculatory
duct obstruction due to calculi and or cysts present-
ing with hemospermia can also be managed success-
fully endoscopically with a transurethral incision.[39,40]
CONCLUSIONS
In most young patients hemospermia is idiopathic, or
associated with an infectious etiology and is often tran-
sient where a cause may never be found. Hemosper-
mia is generally of inflammatory origin in the younger
patients, where as it is often due to urethritis, prostati-
tis or epididymo-orchitis, but in the elderly men, it is
generally due to benign or malignant prostatic tumors.
When it occurs as a poly-symptomatic disorder or when
it persists in the elderly, they should be investigated
thoroughly to rule out more serious underlying disor-
The sanguineous sperm (hemospermia)–current appraisal and review
Indian J Surg | December 2005 | Volume 67 | Issue 6
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ders such as malignancy. Transrectal ultrasound
(TRUS) should be the initial investigative modality of
choice once an infectious etiology has been ruled out.
If TRUS is inconclusive a fast spin echo magnetic res-
onance imaging should be considered. Should all oth-
er imaging modalities fail to conclude a definite diag-
nosis a cystourethroscopy may be considered.
Most cases of hemospermia can be evaluated along the
lines of the stepwise clinical diagnostic algorithm as
outlined in Table-3. Whilst an extensive workup may
not be indicated in all such patients, we recommend
the suggested workup in selected symptomatic and
recurrent cases of hemospermia associated with other
disorders. Thus primary or solitary hemospermia (mon-
osymptomatic) may be assessed by urinalysis, semi-
nal cytology, evaluation for hypertension, and reassur-
ance of the patient. Secondary or persistent and recur-
rent of hemospermia and or polysymptomatic hemos-
permia are best differentiated and clarified by a com-
bination of TRUS, cystoscopy, and or magnetic reso-
nance imaging.[32] TRUS, IVP, MRI and cystoscopy may
be indicated only in select cases. Treatment ought to
be tailored to the outcome of the investigations and
the final diagnosis. No specific therapy may be indi-
cated for the idiopathic cases.
Table 3: Clinical algorithm
Pediatric/elderly Young adult/adolescent
(Primary) Mono-symptomatic (Secondary) Poly-symptomatic
Semen cytology Semen cytology
Clear Hemospermia Hemo-pyospermia
Consider congenital/neoplastic causes Consider inflammatory/iatrogenic causes
TRUS Urine-semen analysis & C/s, PSA,STS
If sterile pyuria consider other infections
Urine-AFB, PCR (Rule out TB),EPS
Serology: Rule out CMV/HIV/Ch.Tr/ S.Hm
Diagnosis No diagnosis Diagnosis confirmed
SV/ED cyst calculi
Manage endoscopically Appropriate antibiotics
MRI (Fast spin echo)
Recurrent CURED Not Cured
Cyst aspiration cytology Follow up 3 monthly
Rule out malignancy Consider long-term antibiotics
Metabolic abnormality
No diagnosis If C/s sterile rule out prostatodynia
Consider Seminal Vesiculography – CECT- Cystourethroscopy-Biopsy
Diagnosis of EDO/polyps confirmed No definite Repeat 3 mths
Diagnosis later
TRUS- Transrectal ultrasound; PSA- Prostate specific antigen; STS-Serological test for syphilis, CMV-Cytomegalovirus; Ch Tr-chlamydia trachomatis; S.Hm-
Schistosoma hematobium; EDO-Ejaculatory duct obstruction. E PS: Expressed prostatic secretions, CECT- Contrast enhanced computerized tomography.
Singh I
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The sanguineous sperm (hemospermia)–current appraisal and review
