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Hemospermia, or hematospermia, is a disturbing symptom that produces extreme anxiety in sexually active males. Most seek medical attention after one or two occurrences. Any process that results in trauma or other injury (e.g., tumor with erosion), inflammation, or infection of the male ejaculatory system may result in bloody semen.23 The most common cause of hematospermia is iatrogenic trauma from instrumentation of the urinary tract or radiation therapy. Patients over 40 in particular may have tumors of the prostate or elsewhere in the ejaculatory system. Benign prostatic hypertrophy can cause hematospermia. In patients under 40, common causes are infections and inflammatory conditions, including prostatitis, seminal vesiculitis, urethritis, sexually transmitted diseases, epididymo-orchitis, calculi with inflammation, and tuberculosis. Testicular tumors occur in the younger population. Vascular abnormalities and cysts causing ductal obstruction are less common causes. As with hematuria, systemic factors may cause hematospermia, including hemophilia, other coagulopathy, oral anticoagulation, severe hypertension, leukemia or other hematologic disease, lymphoma, and scurvy.

A careful history, including sexual history, recent urologic procedures, medications, and HIV and tuberculosis risk factors, should be taken in the emergency department. The patient's general health and condition, vital signs, abdomen, external genitalia, and prostate should be examined. Because hematospermia may be the initial and only presenting complaint in underlying urologic disease, a urinalysis is generally warranted, and treatment and disposition are directed by the urinalysis findings (see "Diagnosis," under "Hematuria," above).

Hematospermia has long been considered a benign condition and is usually diagnosed as idiopathic even after a complete urologic workup. It is not uncommon after vigorous sexual activity. Infection, including sexually transmitted disease, should be considered and treated appropriately in the emergency department. In the absence of other reasons for an expedited workup or admission, patients should be referred to a urologist for follow-up and further outpatient evaluation. Patients under 40 can be reassured that the vast majority of cases of hematospermia in their age group are benign, self-limited, and idiopathic. While all patients with hematospermia should be referred to a urologist, those over 40 are at higher risk for cancer and should be strongly advised to seek further evaluation by a urologist even when there is spontaneous resolution of hematospermia.

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