Our Greatest Wealth Is Health

Andrew Siegel MD  9/2/17

Hematospermia is medical speak for a bloody ejaculation. It is a not uncommon occurrence, usually resulting from inflammation of one of the male reproductive parts, typically the prostate or seminal vesicles.  As scary as it is, it is rarely indicative of a serious underlying disorder.  Like a nosebleed, it can be due simply to a ruptured blood vessel. It is almost always benign and self-limited,  typically resolving within several weeks. On occasion it may become recurrent or chronic, causing concern and anxiety, but again, rarely due to a serious problem.

Factoid: The most common cause of a bloody ejaculation is following a prostate biopsy.

Thank you, Wikipedia, for image above, public domain

What is semen?

Semen is a nutrient vehicle for sperm that is a concoction of secretions from the testes, epididymis, urethral glands, prostate gland, and seminal vesicles.  The clear secretions from the urethral glands account for a tiny component, the milky white prostate gland secretions for a small amount of the fluid, and the viscous secretions from the seminal vesicles for the bulk of the semen. Sperm makes up only a minimal contribution.

Factoid:  After vasectomy the semen appears no different since sperm make up a negligible portion of the total seminal volume.

What exactly occurs during ejaculation?

After a sufficient level of sexual stimulation is achieved (the “ejaculatory threshold”), secretions from the prostate gland, seminal vesicles, epididymis, and vas deferens are deposited into the part of the urethra within the prostate gland.  Shortly thereafter, the bladder neck pinches closed while the prostate and seminal vesicles contract and the pelvic floor muscles spasm rhythmically, sending wave-like contractions rippling down the urethra to propel the semen out.

Factoid:  Ejaculation is an event that takes place in the penis; orgasm occurs in the brain.

Factoid: It is the pelvic floor muscles that are the muscle power behind ejaculation.  Remember this: strong pelvic muscles = strong ejaculation.

Since the prostate and seminal vesicles contribute most of the volume of the semen, bleeding, inflammation or other pathology of these organs is usually responsible for bloody ejaculations. The bleeding may cause blood in the initial, middle, or terminal portions of the ejaculate.  Typically, blood arising from the prostate occurs in the initial portion, whereas blood arising from the seminal vesicles occurs later. The color of the semen can vary from bright red, indicative of recent or active bleeding, to a rust or brown color, indicative of old bleeding.

What are some of the causes of blood in the semen?

• Infection or inflammation (urethritis, epididymitis, orchitis, prostatitis, seminal vesiculitis, etc.)
• Ruptured blood vessel, often from intense sexual activity
• Reproductive organ cysts or stones
• Following prostate biopsy (from numerous needle punctures); following vasectomy
• Pelvic trauma
• Rarely malignancy, most commonly prostate cancer and less commonly, urethral cancer
• Coagulation issues or use of blood thinners

 How is hematospermia evaluated and treated?

A brief history reveals how long the problem has been ongoing, the number of episodes, the appearance of the semen and the presence of any inciting factors and associated urinary or sexual symptoms. Physical examination involves examination of the genitals and a digital rectal examination to check the size and consistency of the prostate. Laboratory evaluation is a urinalysis to check for urinary infection and blood in the urine, and a PSA (prostate specific antigen) blood test.  At times a urine culture and/or semen culture needs to be done.

Hematospermia is typically managed with a course of oral antibiotics because of the infection/inflammation that is often the underlying cause.  In most cases, the situation resolves rapidly.

If the bloody ejaculations continue, further workup is required.  This may involve imaging with either trans-rectal ultrasonography (TRUS) or magnetic resonance imaging (MRI) and at times, cystoscopy. TRUS is an office procedure in which the prostate and seminal vesicles are imaged by placing an ultrasound probe in the rectum. MRI imaging is performed at an imaging center under the supervision of a radiologist. The MRI provides a more thorough diagnostic evaluation, but is more expensive and time consuming.  Both TRUS and MRI can show dilated seminal vesicles, cysts of the ejaculatory ducts, prostate or other reproductive organs, and ejaculatory or seminal vesicle stones.  MRI can also show sites suspicious for prostate cancer. Cystoscopy is a visual inspection of the inner lining of the urethra, prostate and bladder with a small-caliber, flexible instrument. Treatment is based on the findings of the imaging and diagnostic studies, but again, it is important to emphasize the typical benign and self-limited nature of hematospermia.

Bottom Line: Blood in the ejaculation is not uncommon and is frightening, but is usually benign and self-limited and easily treated. In the rare situation where it persists, it can be thoroughly evaluated to assess the underlying cause.  If you experience hematospermia, visit your friendly urologist to have it checked out.

Wishing you the best of health,

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Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

The aforementioned books will teach men and women, respectively, how to strengthen their pelvic floor muscles.

Tags: Andrew Siegel MD, blood, bloody ejaculation, bloody semen, ejaculation, hematospermia, urology

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