Haemospermia
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)
- Trauma (to Testicles or Perineum)
- Epididymo-Orchitis
- Urethritis
- Urinary Tract Infection
Occasional Diagnoses
- Blood Clotting Disorder or Anticoagulation
- Calculi in the Prostate
- Bladder Cancer
- Prostate Cancer
- Testicular Cancer
Rare Diagnoses
- Tuberculosis
- Schistosomiasis
- Malignant Hypertension
- Structural Problems (Such as Urethral Strictures or Polyps)
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Unknown | Prostatitis | Post-op | GU infection | Trauma | |
|---|---|---|---|---|---|
| Persistent | Possible | Possible | No | Possible | No |
| Recent Surgical Intervention | No | Possible | Yes | Possible | No |
| Recent Trauma | Possible | No | No | No | Yes |
| Urinary Tract Symptoms | No | Possible | Possible | Yes | No |
| Prostate Markedly Tender on PR | No | Yes | Possible | No | No |
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.