Blood in Semen

Semen is the male ejaculate that contains sperms, prostatic and other glandular secretions and some enzymes. Under normal circumstances, blood is not considered a normal constituent of semen; however, in certain cases, broken or abraded blood vessels or traumatic injuries to the inguinal region may lead to extravasation of blood in the semen. Depending upon the nature and intensity of damage to the genital apparatus, urine or pus may also occur in the semen.

Blood in semen (also refers to hematospermia) is a serious and frightening complaint but fortunately in most cases, the cause is benign. It is believed that as many as 15% cases of blood in semen are idiopathic i.e. no cause can be ascertained (1).

Causes of Blood in Semen

Most common causes of blood in semen are:

Physiological causes:

Blood in semen is normal in certain cases; such as:

• A recent history of a medical or surgical procedure of inguinal region (such as prostate biopsy, prostate resection surgery etc.)
• Vasectomy is the most popular method for permanent sterilization in males. Blood in semen is common during first few weeks of post-vasectomy period. Usually, the symptoms resolves spontaneously without needing any further intervention.
• Side effect of certain drugs: Drugs like Rifampin (prescribed for the management of Tuberculosis) is known to stain body secretions orange, which may mimic blood.

Other less common causes include:

• Radiation therapy for the management of a malignant lesion.
• Injection therapy for hemorrhoids.
• Prostate examination.
• Excessive/ vigorous sexual activity
• Masturbation

Pathological causes:

In the absence of a physiological cause/ explanation of blood in semen; your healthcare provider will explore pathological causes; such as:

• Infection: Sexually transmitted diseases and other types of infection can present with semen in blood. Most common ones are; chlamydia, gonorrhea, syphilis and herpes. Other symptoms to watch for are; painful urination, urgen

• cy, frequency of urination, flank pain etc.
• Inflammation: Inflammation of any part of genital tract that serves as a conduit to semen can also present with hematospermia. According to a new study reported in the Journal of Andrology (1), investigators suggested that more than 39% cases of blood in semen are due to inflammatory/ infection disorders of genital region. Most common inflammatory conditions include; prostatitis, urethritis, orchitis or epididymitis.
• Testicular cancer: Testicular cancer often presents with recurrent episodes of blood in semen in males over the age of 40 years. Other symptoms include weight loss, lower abdominal pain and changes in the size, texture of feel of testes.
• Trauma to inguinal region: Trauma to testes, urethra, penis or any other part of genito-urinary tract can also presents with blood in semen.

Other causes include:

• Prostate cancer
• Benign or malignant growths in the genital tract or urinary tract
• Amyloidosis
• Prolonged sexual abstinence
• Interruption in the sexual intercourse
• Schistosomiasis
• Warfarin side effects
• Posterior urethral hemangioma
• Benign prostatic hypertrophy
• Hypertension
• Leukemia

How to address the complaint of blood in semen

In most cases, the symptoms resolves spontaneously. You probably don’t even have to see a healthcare professional if you are young (under 40 years of age) and have recently undergone a medical or surgical procedure that may explain mild/ transient genito-urinary bleeding. However, it is highly recommended to seek medical help to identify the cause and pathophysiology for proper management; if:

• You are over 40 years of age
• Experiencing frequent episodes of copious bleeding in semen/ urine
• Have a strong family history of malignant lesions
• Experiencing other troubling symptoms that are suggestive of a serious issue such as painful and frequent urination, blood in urine, burning sensation while passing urine, painful ejaculation, feeling of distended bladder, urinary retention or incontinence, urgency, flank pain, fever etc.

The treatment or management of blood in semen is dependent on the primary cause and related pathophysiological factors. For example, antibiotics are usually recommended to address blood in semen due to sexually transmitted diseases. Surgical intervention is needed to address organic lesions or polys after careful evaluation by transrectal ultrasound and other reliable diagnostic tools (3).

References

1. Li, Y. F., Liang, P. H., Sun, Z. Y., Zhang, Y., Bi, G., Zhou, B., ... & Jin, F. S. (2012). Imaging diagnosis, transurethral endoscopic observation, and management of 43 cases of persistent and refractory hematospermia. Journal of andrology, 33(5), 906-916.

2. Han, H., Zhou, X. G., Fan, D. D., Tian, L., & Zhang, X. D. (2015). An Unusual Etiology for Hematospermia and Treatments that were Successful. Urology, 86(4), 740-743.

3. Raviv, G., Laufer, M., & Miki, H. (2013). Hematospermia—the added value of transrectal ultrasound to clinical evaluation: Is transrectal ultrasound necessary for evaluation of hematospermia?. Clinical imaging, 37(5), 913-916.