Archive for February, 2023

Blood in the Semen: Not Such a “Jizzaster” As One Would Think

February 25, 2023

Andrew Siegel MD   2/25/2023

Hematospermia, aka hemospermia, is medical-speak for blood in the semen. It is a not uncommon occurrence that usually results from an inflammatory condition within the male reproductive system, often involving the prostate and/or seminal vesicles.  As frightening and as much of a source of worry as it is, it is rarely indicative of a serious underlying disorder.  Like a nosebleed, it may be caused by a blood vessel that ruptures at the time of ejaculation. It is typically benign and self-limited, often resolving within several weeks. On occasion, it may become recurrent or chronic, causing concern and anxiety, but rarely is it based on a serious problem.

Thank you, Wikipedia, for above image of male reproductive anatomy, public domain

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, and the viscous secretions from the seminal vesicles for the bulk of the semen. Sperm makes up only a minimal contribution.

After a sufficient level of sexual stimulation is achieved (“ejaculatory threshold”), this concoction of secretions gets deposited into the prostatic urethra.  Shortly thereafter, the bladder neck pinches closed while the prostate and seminal vesicles contract and the pelvic floor muscles pulsate rhythmically, sending wave-like contractions down the urethra to propel forth the semen.

Brief video explaining and illustrating the ejaculatory process.

Bleeding, inflammation, or other pathologies of the prostate or seminal vesicles are usually responsible for bloody ejaculation since these structures produce the bulk of the semen. Blood may be apparent 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.

There are numerous causes of hematospermia:

  • Following prostate biopsy (this is the most common cause)
  • Following vasectomy
  • Bacterial or viral infection or inflammation, most commonly of the prostate and seminal vesicles
  • Ruptured blood vessel, often from intense sexual activity
  • Prostate, seminal vesicle, or ejaculatory duct cysts or stones
  • Pelvic trauma
  • Malignancy (extremely rare, most commonly prostate cancer)
  • Coagulation issues or use of blood thinners

Younger patients (< 40-years-old) who have transient or episodic hematospermia and are asymptomatic are less concerning than the older male population with hematospermia.  Older patients who have persistent hematospermia and are symptomatic mandate a more extensive evaluation.  A brief history reveals how long the problem has been ongoing, the number of episodes, the appearance of the semen, the presence of any inciting factors, and associated urinary or sexual symptoms. Physical examination of the genitals and a digital rectal examination to check the size and consistency of the prostate gland are performed. Laboratory evaluation consists of a urinalysis to check for urinary infection and blood in the urine and a PSA (prostate specific antigen) blood test, with the caveat that the PSA may be elevated on the basis of an infection.  Urine culture and/or semen culture are obtained according to circumstances.

Although hematospermia often resolves spontaneously without pharmacological intervention, it is often empirically managed with a course of oral antibiotics since infection or inflammation are commonly the underlying cause.  In most cases, the situation resolves rapidly. Under the circumstance of persistent hematospermia, imaging with either transrectal ultrasonography (TRUS) or magnetic resonance imaging (MRI) is obtained. Further evaluation using cystoscopy is indicated at times. TRUS is an office procedure in which the prostate and seminal vesicles are imaged via an ultrasound probe placed in the rectum. MRI is performed at an imaging center under the supervision of a radiologist and provides a more thorough diagnostic evaluation but is more expensive and time consuming.  Both TRUS and MRI can reveal dilated seminal vesicles, cysts of the ejaculatory ducts, prostate or other reproductive organs, and ejaculatory or seminal vesicle stones.  MRI can also demonstrate sites suspicious for prostate cancer. Cystoscopy is a visual inspection of the urethra, prostate, and bladder with a small-caliber flexible instrument. Treatment is predicated upon the findings of the imaging and diagnostic studies.

Finasteride, often used as treatment for benign prostate hyperplasia, has been used effectively to manage refractory hematospermia after excluding other organic causes.  Surgical procedures to treat hematospermia are only rarely necessary.

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro AreaInside 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. He is a urologist at New Jersey Urology, one of the largest urology practices in the United States.  He is the co-founder of PelvicRx and Private Gym.  His latest book is Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families. 

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Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

PROSTATE CANCER 20/20 is now available at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours). 

Dr. Siegel’s other books:

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

Video on THE KEGEL FIX

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food