This is an uncommon presentation – but one we may see increasingly frequently as men become less reticent about coming to the doctor. As with any symptom involving leakage of blood, anxiety levels tend to run high. This shouldn’t transfer to the GP, though – it is unusual for the symptom to have a sinister cause.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Unknown (at Least 50%; the Majority are Probably Secondary to Forgotten or Unnoticed Trauma)
  • Prostatitis
  • Post-Operative (Prostate Surgery, Biopsy or Extracorporeal Shock Wave Lithotripsy)
  • Genito-Urinary Infection (Epididymo-Orchitis, Urethritis, UTI)
  • Trauma (to Testicles or Perineum)

Occasional Diagnoses

  • Blood Clotting Disorder or Anticoagulation
  • Calculi in the Prostate
  • Carcinoma: Prostate, Testicles, Bladder or Seminal Vesicles

Rare Diagnoses

  • Tuberculosis
  • Schistosomiasis
  • Malignant Hypertension
  • Structural Problems (Such as Urethral Strictures or Polyps)

Ready reckoner

Key distinguishing features of the most common diagnoses

UnknownProstatitisPost-opGU infectionTrauma
Recent Surgical InterventionNoPossibleYesPossibleNo
Recent TraumaPossibleNoNoNoYes
Urinary Tract SymptomsNoPossiblePossibleYesNo
Prostate Markedly Tender on PRNoYesPossibleNoNo

Possible investigations

Likely: Urinalysis, MSU.

Possible: FBC, ESR/CRP, PSA, urethral swab.

Small Print: INR, clotting screen, seminal fluid culture, transrectal ultrasound, prostate biopsy, urethroscopy.

  • Urinalysis: Protein, nitrites, leucocytes and possible haematuria in any genito-urinary infection or prostatitis. Haematuria possible in malignancy and schistosomiasis.
  • MSU: To confirm infection and identify pathogen.
  • FBC and ESR/CRP: WCC may be elevated in infection; Hb may be reduced and ESR/CRP raised in malignancy; ESR/CRP also raised in infection.
  • PSA: The pros and cons of this test might be discussed as a pointer to prostatic carcinoma.
  • Urethral swab: If urethritis suspected (best taken at GUM clinic).
  • INR, clotting screen: If patient on warfarin or a bleeding disorder suspected.
  • Other investigations (usually hospital-based): These might include seminal fluid culture to investigate deep-seated infection; transrectal ultrasound and prostatic biopsy for detailed investigation of prostate; urethroscopy/cystoscopy if felt to be a structural urethral or bladder problem.

Top Tips

  • A frank and open approach, using plain language, is important for the patient to feel comfortable and capable of describing an accurate history.
  • Do not underestimate the patient’s level of anxiety – and ensure it’s properly addressed. Most men with this symptom are convinced they have serious pathology.
  • The approach with this symptom has more to do with deciding on further action than establishing a precise diagnosis. This is because assessment in primary care rarely reveals any underlying pathology – management is more likely to be influenced by the patient’s age and the history than the clinical findings (see the following point).
  • Men under the age of 40 with short-lived symptoms do not require referral, as the chance of significant pathology is miniscule. Older men – and those with persistent or recurrent haemospermia, or abnormalities on initial assessment – require referral for further assessment.

Red Flags

  • A serious underlying cause is rare but should be considered in men over the age of 40 who have more than one episode.
  • The chances of significant pathology are increased by the finding of microscopic haematuria – refer these cases.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.