Hematospermia: etiological and management considerations

Hematospermia in a Transgender Woman with Evidence for Endometrial Tissue in the Prostate

Background/Objective

The frequency of hematospermia in transgender women is unknown. This report aimed to describe the development of hematospermia in a transgender woman.

Case Report

A 35-year-old transgender woman treated with estradiol valerate and leuprolide presented with painless rust-tinged ejaculate, urethral bleeding after ejaculation, and intermittent hematuria. Her medical history included gastroesophageal reflux disease, internal hemorrhoids, and attention deficit hyperactivity disorder with negative tobacco smoking and urologic history. Additional medications included emtricitabine-tenofovir disoproxil fumarate and fexofenadine. Physical examination did not reveal constitutional or genitourinary abnormalities. Urinalysis and culture disclosed rare white blood cells with gram-variable bacilli. The chlamydia, gonorrhea, and human immunodeficiency virus test results were negative. Abdominal computed tomography did not reveal bladder or prostate cancer, calcifications, inflammation, or cysts. She continued to have symptoms after this initial workup. One year after the initial symptom onset, transrectal ultrasound disclosed a 1.7-cm midline posterior prostatic cyst with hemorrhagic products, later revealed by magnetic resonance imaging as communicating with the left seminal vesicle. Two ultrasound-guided transperineal biopsy samples revealed benign prostatic tissue with a small focus of Müllerian or endometrial-type tissue, evidenced by immunopositivity for paired-box gene 8 and estrogen receptor in epithelium and cluster of differentiation 10 immunopositivity in stroma. After medical consultation, the patient underwent prostatic cyst aspiration, resection of the transurethral ejaculatory ducts, and orchiectomy. She did not experience any complications after these procedures.

Discussion

The etiology of hematospermia may be idiopathic, iatrogenic, anatomic, or pathologic.

Conclusion

Occult endometriosis or ectopic Müllerian epithelial tissue growth may occur in transgender women taking feminizing gender-affirming hormone therapy.

[And there was Zinner's syndrome-a rare differential diagnosis]

Zinner's syndrome is a rare congenital abnormality of the Wolffian ducts in male patients. It consists of the triad of renal agenesis, ipsilateral seminal vesicle dilatation, and obstruction of the ejaculatory duct. Symptoms often occur after puberty and can include hematospermia, painful ejaculation, dysuria, and local discomfort. We present the case of a 15-year-old patient with this rare condition who was treated surgically after the diagnosis was confirmed.

Hematospermia Etiology, Diagnosis, Treatment, and Sexual Ramifications: A Narrative Review

INTRODUCTION

Hematospermia (HS) is the presence of blood in ejaculatory fluid. It is a rare condition that is historically idiopathic or associated with sexual behavior. Technological advances have identified many of the etiologies behind HS, improving treatment. Though often benign, HS remains a source of considerable sexual anxiety for patients. Few papers have outlined a diagnostic and therapeutic approach to HS, and none have explicitly addressed its sexual consequences.

OBJECTIVES

To provide a comprehensive overview of HS, emphasizing its sexual ramifications.

METHODS

A PubMed literature search was performed through May 2021 to identify all relevant publications related to etiology, diagnosis, treatment, and sexual effects of HS. Original research and reviews were analyzed, and pertinent studies were included in this review.

RESULTS

Iatrogenic interventions (eg, transrectal ultrasound-guided prostate biopsies) are the most common cause of HS. Infection and/or nonspecific inflammation is the most common non-iatrogenic etiology. Malignancies, including prostate, testicular, and other genitourinary cancers, are rarely the cause of HS. Diagnostic approaches to HS can be organized according to patient age (less than or greater than 40 years old), persistence of bleeding, and the presence/absence of concerning symptoms. Though HS often spontaneously resolves, treatment may require various medications (eg, antibiotics, anti-inflammatories) or surgical interventions. HS has several sexual ramifications, including libido-affecting anxiety, social repercussions from sexual partners and non-sexual affiliates, increased risk of erectile dysfunction or transmission of sexual infections, and compromised fertility, especially when cryopreservation is utilized.

CONCLUSION

HS may significantly affect sexual health through several mechanisms, though there is a paucity of formal data on this subject. Further research is needed to fully understand the severity and extent of HS's effect on sexual well-being, especially in those with refractory bleeding. Drury RH, King B, Herzog B, et al. Hematospermia Etiology, Diagnosis, Treatment, and Sexual Ramifications: A Narrative Review. Sex Med Rev. 2021;XX:XXX-XXX.

Real-time transrectal ultrasound-guided seminal vesiculoscopy for the treatment of patients with persistent hematospermia: A single-center, prospective, observational study

This study aimed to describe endoscopic anatomy of the seminal tract and summarize our experience of transutricular seminal vesiculoscopy (TSV) guided by real-time transrectal ultrasonography (TRUS) in managing persistent hematospermia. A total of 281 consecutive patients with persistent hematospermia who underwent TSV with or without real-time TRUS were enrolled in this single-center, prospective, observational study. The median follow-up period was 36.5 (range: 8.0–97.5) months. TSV was successfully performed in 272 (96.8%) patients. The approach of a 4.5/6 F rigid vesiculoscope entering the seminal tract was categorized into four types on the basis of endoscopic presentation of the ejaculatory duct orifice and verumontanum. Seven (2.6%), 74 (27.2%), 64 (23.5%), and 127 (46.7%) patients had Types I (through the ejaculatory duct in the urethra), II (through the ejaculatory duct in the prostatic utricle), III (transutricular fenestration through a thin membrane), and IV (real-time transrectal ultrasound-guided transutricular fenestration) approach, respectively. In patients who successfully underwent surgery, bleeding occurred in the seminal vesicle in 249 (91.5%) patients. Seminal vesiculitis, calculus in the prostatic utricle, calculus in the ejaculatory duct, calculus in the seminal vesicle, prostatic utricle cysts, and seminal vesicle cysts were observed in 213 (78.3%), 96 (35.3%), 22 (8.1%), 81 (29.8%), 25 (9.2%), and 11 (4.0%) patients, respectively. Hematospermia was alleviated or disappeared in 244 (89.7%) patients 12 months after surgery. Fifteen patients had recurrent hematospermia, and the median time to recurrence was 7.5 (range: 2.0–18.5) months. TSV guided by TRUS may contribute to successful postoperative outcomes in managing persistent hematospermia.

Transrectal ultrasound-guided seminal vesicle catheterization with continuous antibiotic infusion for the treatment of refractory hematospermia

The aim of the present study was to describe transrectal ultrasound (TRUS)-guided seminal vesicle catheterizations with continuous antibiotic infusion in patients with persistent hematospermia. A retrospective record review of 45 patients with refractory hematospermia treated with TRUS-guided seminal vesicle catheterization between 2010 and 2017 was performed. Seminal vesicle puncture and catheterization was performed under TRUS guidance for all patients. Antibiotic irrigation was used to rinse the seminal vesicle until the outflow fluid was clear. The trocar sleeve was left in situ and fixed on the skin of the perineum at the end of the procedure. All patients underwent a 24-h continuous infusion of antibiotic solution through the catheter. The patients were followed up to 3 years for the presence of hematospermia. The duration of refractory hematospermia was between 6 months and 9 years. A total of 14 patients exhibited consecutive hematospermia, while the remaining patients exhibited intermittent episodes. On TRUS, 15 cases of ejaculatory duct cyst, 7 cases of ejaculatory duct expansion, 3 cases of ejaculatory duct stones, 6 cases of seminal vesicle expansion, 8 cases of seminal vesicle stones and 5 cases of seminal vesicle wall or ejaculation wall calcification were diagnosed. A total of 41 patients completed the scheduled treatment plan; however, the catheter was dissociated on the 3rd or 4th day of catheterization in 4 patients. After a 1-3 year follow-up, hematospermia was not observed in 42 patients (93.33%) with recurrence in the remaining 3 patients. In conclusion, TRUS-guided seminal vesicle catheterization with continuous antibiotic infusion appeared to be a safe and effective method for the treatment of hematospermia.

Laboratory and clinical management of leukocytospermia and hematospermia: a review

Leukocytospermia and hematospermia are defined as the presence of abnormally high white blood cell and red blood cell concentration in the semen, respectively. Numerous etiologies and various implications on fertility have been identified. In a small proportion of men, the presence of white blood cells or red blood cells can adversely affect sperm quality by the production of reactive oxygen species. Several methods have been used to assess the presence of white blood cells and red blood cells in samples, such as identification of round cells, immunohistochemical staining using monoclonal antibodies, the Endtz test, the peroxidase test, and flow cytometry or microscopy. In addition, techniques have been identified to separate sperm samples from white blood cells and red blood cells for cryopreservation to improve outcomes in assisted reproductive technology. In this review, laboratory and clinical management of leukocytospermia and hematospermia are discussed. Currently available diagnostic methods and treatment options are outlined, and available optimal cryopreservation techniques for samples with white blood cells or red blood cells are summarized.

Transurethral resection of ejaculatory duct combined with seminal vesiculoscopy for management of persistent or recurrent hemospermia in men with ejaculatory duct obstruction

BACKGROUND

Persistent or recurrent haemospermia often occurs in individuals with ejaculatory duct obstruction (EDO). This study aimed to evaluate the efficacy and safety of transurethral resection of the ejaculatory duct (TURED) combined with seminal vesiculoscopy in treating persistent or recurrent haemospermia in men with EDO.

METHODS

From June 2014 to March 2018, 103 consecutive patients with EDO who underwent TURED combined with seminal vesiculoscopy for persistent or recurrent haemospermia at the Department of Urology of West China Hospital were enrolled into this retrospective study. The patients were evaluated mainly by detailed history-taking and performing semen analysis, transrectal ultrasonography, and magnetic resonance imaging.

RESULTS

Among the 103 patients, 79 (76.70%) had cysts of the lower male genitourinary tract; 63 (61.17%) had blood clots; and 32 (31.07%) had calculi in the seminal vesicle and/or prostatic utricle. The duration of postoperative follow-up was 12 months, and the symptoms of haemospermia disappeared in 96 (93.20%) patients. There was no significant difference in the semen PH and sperm count before and after surgery; however, the ejaculate volume and sperm motility significantly improved postoperatively. Except for two cases of acute urinary retention and one case of watery ejaculate after surgery, no severe postoperative complications, including epididymitis, urethral stricture, urinary incontinence, retrograde ejaculation, or rectal injury, were observed.

CONCLUSION

TURED combined with seminal vesiculoscopy is a suitable method for the diagnosis and treatment of persistent or recurrent haemospermia in men with EDO.

Etiology of 305 cases of refractory hematospermia and therapeutic options by emerging endoscopic technology

To investigate the surgical outcomes of vesiculoscopy on refractory hematospermia and ejaculatory duct obstruction (EDO), the clinical data (including pelvic magnetic resonance imaging (MRI) examinations and the long-term effects of endoscopic treatment) from 305 patients were analyzed. Four main etiologic groups were found on MRI. We found that 62.0% (189/305) of patients showed abnormal signal intensity in MRI investigations in the seminal vesicle (SV) area. Cystic lesions were observed in 36.7% (112/305) of the patients. The third sign was dilatation or enlargement of unilateral or bilateral SV, which were observed in 32.1% (98/305) of the patients. The fourth sign was stone formation in SV or in an adjacent cyst, which was present in 8.5% (26/305) of the patients. The transurethral endoscopy or seminal vesiculoscopy and the related procedures, including fenestration in prostatic utricle (PU), irrigation, lithotripsy, stone removal, biopsy, electroexcision, fulguration, or transurethral resection/incision of the ejaculatory duct (TURED/TUIED), chosen according to the different situations of individual patients were successfully performed in 296 patients. Fenestrations in PU+ seminal vesiculoscopy were performed in 66.6% (197/296) of cases. Seminal vesiculoscopy via the pathological opening in PU was performed in 10.8% (32/296) of cases. TURED/TUIED + seminal vesiculoscopy was performed in 12.8% (38/296) of cases, and seminal vesiculoscopy by the natural orifices of the ejaculatory duct (ED) was performed in 2.4% (7/296) of cases. Electroexcision and fulguration to the abnormal blood vessels or cavernous hemangioma at posterior urethra were performed in 7.4% (22/296) of cases. Two hundred and seventy-one patients were followed up for 6-72 months. The hematospermia of all the patients disappeared within 2-6 weeks, and 93.0% of the patients showed no further hematospermia during follow-up. No obvious postoperative complications were observed. The transurethral seminal vesiculoscopy technique and related procedures are safe and effective approaches for refractory hematospermia and EDO.

A prospective study on aetiology and outcome of haemospermia from a urology unit in Sri Lanka

Introduction:

Haemospermia is an alarming symptom for ordinary members of the public. The worry become greater as it has been described as a warning sign of a prostate cancer in the media.

Objectives:

The aim of the study was to identify the aetiological factors and outcome of haemospermia in a cohort of patients.

Methods:

All patients with newly diagnosed haemospermia treated at the urology unit of Colombo South Teaching Hospital over a period of 5 years (2013–2018) constituted the study sample. Data related to demographics, symptomatology, clinical findings, investigations, treatment given and outcome during follow-up were recorded prospectively.

Results:

There were 94 men with haemospermia who sought treatment during the study period. Mean age was 43.7 years (range: 23–67, median = 41). Twenty-seven (29%) patients had clinical evidence of prostatitis and/or a positive seminal fluid culture. One patient each had prostate carcinoma, prostatic cyst, severe hypertension, sclerotherapy for haemorrhoids, post-chemotherapy and post-epididymectomy. The patient who had high blood pressure (220/150 mmHg) was found to have mesangio-proliferative glomerulonephritis. In 61 (65%) patients, there was no identifiable cause.

Conclusion:

The majority of patients with haemospermia are aged < 45 years and have a benign aetiology. As haemospermia is self-limiting in the majority of cases, extensive investigations are unnecessary. Advanced and invasive tests should be confined to those with abnormal clinical findings, and to those with persistent or recurrent haemospermia.

Level of evidence:

Level IV.

Hematospermia-a Symptom With Many Possible Causes

BACKGROUND

Hematospermia, or blood in the ejaculate, is a symptom with many possible causes that often gives rise to worry. Precise figures on its prevalence are unavailable. It is most common in men under 40, and its cause is usually benign; nonetheless, even a single episode of hematospermia calls for a basic diagnostic evaluation.

METHODS

This review is based on pertinent articles re trieved by a search in PubMed with the key words "hemato spermia," "hemospermia," "ejaculation," "male semen," and "transrectal ultrasound."

RESULTS

A diagnostic algorithm for hematospermia is described. The most common cause is iatrogenic trauma, in particular transrectal ultrasound-guided prostate biopsy to rule out prostate cancer. Urogenital infections are the second most common cause. Pathological changes of the prostate should be considered along with systemic causes, e.g., arterial hypertension or various hematologic disorders. A single event in men under 40 should be evaluated by precise history-taking, a meticulous physical examination including blood-pressure measurement, and urinalysis. Repeated episodes, or hematospermia in men over 40, calls for additional evaluation with further laboratory tests, imaging studies, and, in some cases, interventional diagnostic procedures.

CONCLUSION

Further tests, preferably imaging studies, seem a reasonable way to detect or exclude potential causes of hematospermia, especially malignant ones. The treatment is directed at the underlying cause.

Contemporary management of ejaculatory dysfunction

Although erectile dysfunction is the most common disorder of male sexual health, ejaculatory dysfunction is the most common form of sexual dysfunction experienced by men. Ejaculatory dysfunction covers a broad range of disorders that we have divided into four main categories: premature ejaculation, delayed ejaculation (DE)/anorgasmia, unsatisfactory sensation of ejaculation (including painful ejaculation and ejaculatory anhedonia), and absent ejaculate (including retrograde ejaculation and aspermia). We also cover several special scenarios including hematospermia, spinal cord injury and fertility with anejaculation. In this paper, we will review the anatomy and pathophysiology of normal ejaculation to establish the baseline knowledge of how this pathway can go awry. We will then briefly review the critical diagnostic criteria, pertinent steps in evaluation, risk factors, and causes (if known) for each of the ejaculatory disorders. Finally, the bulk of the paper will discuss current management strategies of each disorder.

Is magnetic resonance imaging helpful in detecting significant prostate cancer in patients with haematospermia, normal prostate specific antigen level and digital rectal examination. A single institution, observational, and retrospective study in a United Kingdom hospital

Introduction

Haematospermia is an uncommon clinical condition that may be associated with prostate cancer. The optimal investigation of haematospermia is unknown. The aim of this study was to investigate haematospermia as a presenting symptom of significant pathology and to assess the diagnostic value of magnetic resonance imaging (MRI).

Material and methods

Patient and treatment parameters were collected from a practice cohort of men referred to a urology center presenting with haematospermia. We used a multivariate logistic regression model to test the independent significance of MRI in detecting prostate cancer (PCa) after adjusting for other known predictors of PCa detection.

Results

A total of 125 men (median age 58 years) were evaluated between 2012-2015. In the univariate and multivariate logistic regression model MRI was a significant predictor of PCa diagnosis after adjusting for age, prostate specific antigen (PSA) and digital rectal examination (DRE) results (Odds Ratio (OR) 14.15, p = 0.001). Of 107 patients who underwent MRI prostate imaging, 31 (28.9%) had reports suspicious of PCa. In 26 patients, other benign conditions were detected on MRI. PCa was detected in 12 (25.5%) of the 47 men (median age 61 years; range 43 to 85) who underwent prostate biopsies. Eight (17%) of these patients had Gleason ≥7 grade cancer. The persistence of haematospermia was not an independent predictor of cancer diagnosis (OR 0.20, p = 0.15).

Conclusions

PCa is not commonly associated with haematospermia. MRI seems to be improving detection rate of a significant PCa, particularly in patients presenting with haematospermia and normal PSA levels and DRE examination. Duration of haematospermia does not predict the presence of PCa.

ACR Appropriateness Criteria® Hematospermia

Most men with hematospermia or hemospermia (HS) are young (<40 years of age), presenting with transient or episodic HS without other signs or symptoms of disease. The condition is self-limiting in most cases and idiopathic in nature. When a cause can be identified, infections of the urogenital tract are the most common. Imaging does not play a role in this patient population. In older men (>40 years of age), clinical screening for prostate cancer is advised. Furthermore, when HS is persistent or has symptoms, causes include obstruction or stricture at the level of the verumontanum, calcifications or calculi in the prostate, ejaculatory ducts or seminal vesicles, and cysts arising within these structures. Noninvasive imaging, predominantly transrectal ultrasound (TRUS) and MRI, can be used in men of any age with persistent or refractory HS, or other associated symptoms or signs. TRUS is considered as the first-line imaging with MRI used when TRUS is inconclusive or negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

An Innovative Technique of Transurethral Seminal Vesiculoscopy with Ultrasonic Lithotripter for Severe, Persistent Hematospermia

BACKGROUND AND PURPOSE

Transurethral seminal vesiculoscopy (TSV) provides an efficient approach to diagnose and treat hematospermia, but still needs further improvement in manipulation and corresponding instruments. In this study, we develop an innovative technique with ultrasonic lithotripter (EMS) to treat severe, persistent hematospermia.

PATIENTS AND METHODS

Data of patients who underwent TSV with or without ultrasonic lithotripter between May 2012 and December 2015 was reviewed. For the innovative procedure, a 3.3F ultrasonic lithotripter was introduced through the working channel of an 8F seminal vesiculoscope to remove calculi, blood clots, or purulent material, whereas in routine procedure, the holmium laser lithotripsy was performed with lower energy (maximum power 10 W). Complication, hematospermia recurrence, the operative time, and postoperative hospitalization were recorded.

RESULTS

A total of 30 patients, 16 in Group A (routine TSV) and 14 in Group B (TSV with ultrasonic lithotripter procedure), were involved in this study. The median follow-up time for patients in Group A and B was 28 and 31 months, respectively. The mean operative time in Group A and B was 66 and 50 minutes, respectively (p < 0.05). All the TSV procedures in Group B were successful, except one patient had a two-stage procedure because of right seminal vesicle stones accompanying with pus. One patient in Group A had the discontinuation of the procedure because of accidental bleeding during stone fragmentation. During the follow-up, two patients in Group A had recurrent hematospermia and underwent the second TSV, whereas no recurrence happened in Group B. No epididymitis, retrograde ejaculation, rectal injury, incontinence, bladder neck contracture, or erectile dysfunction happened in both groups.

CONCLUSION

TSV with ultrasonic lithotripter enables a more reliable, effective, and convenient procedure to diagnose and treat severe, persistent hematospermia. It controls the recurrent hematospermia with less operative time and complication.

Magnetic Resonance Imaging in Hematospermia: Does It Increase Unnecessary Prostate Biopsy?

INTRODUCTION

Hematospermia is an uncommon presentation of prostate cancer. Following the introduction of MRI for patients with hematospermia we evaluated its use and effect on prostate biopsy and cancer detection rates.

MATERIALS AND METHODS

Analysis of patients attending our outpatient department over 2 years was undertaken. Diagnostic workup included digital rectal examination and PSA. Those with abnormal findings or persisting symptoms were offered prostate biopsy. In the second year MRI became available for patients with hematospermia. Abnormal MRI or persisting symptoms were offered biopsy. We compared the frequency of prostate biopsy and cancer detection in patients undergoing MRI and those not having imaging.

RESULTS

Forty-seven patients were referred with hematospermia. Nineteen patients did not undergo MRI; four received prostate biopsy with one adenocarcinoma found. Twenty-four patients had an MRI with 17 biopsies undertaken. Three biopsies revealed adenocarcinoma. In the MRI group 71% of patients underwent prostate biopsy but only 21% from the non-MRI group (p < 0.05). Prostate cancer detection rate in the MRI group was 18% whilst in the non-MRI group was 25% (p = 0.7).

CONCLUSIONS

Our findings indicate that caution should be used with MRI as it can lead to an increase in prostate biopsy with no change in cancer detection rate.

Hematospermia Evaluation at MR Imaging

Hematospermia is a challenging and anxiety-provoking condition that can manifest as a single episode or recur over the course of weeks to months. It is usually a benign self-limiting condition in younger sexually active males without a history of risk factors such as cancer, urogenital malformations, bleeding disorders, and their associated symptoms. However, patients with recurrent, refractory and painful hematospermia with associated symptoms, such as fever, pain, or weight loss, require evaluation through clinical assessment and noninvasive investigations to rule out underlying pathologic conditions such as ejaculatory obstruction, infectious and inflammatory causes, malignancy, vascular malformations, and systemic disorders that increase the risk of bleeding, especially when presenting in older men. If these investigations are negative, the patient should be reassured and treated accordingly. In the recent past, magnetic resonance (MR) imaging has assumed a major role in the investigation of hematospermia due to its excellent soft-tissue contrast and multiplanar capabilities. In this review, we will discuss the potential causes of hematospermia and its diagnostic workup, including pathophysiology, anatomic considerations, the imaging appearance of associated pathologic conditions, and management. (©)RSNA, 2016.

Hyperuricemia: a possible cause of hemospermia

OBJECTIVE

To report our experience with hemospermia and its relation to hyperuricemia.

PATIENTS AND METHODS

Between July 2005 and July 2012, 143 patients with hemospermia presented to the outpatient clinic in our hospital. History, examination, workup, treatment outcomes, and long-term follow-up were reported in a prospective database. Patients were followed up monthly by semen examination till disappearance of hemospermia, then every 3 months for 1 year. We identified 43 patients, who had 4-12 hemospermia attacks for 2-10 months before presentation with no identifiable cause for hemospermia. Of them, 22 had hyperuricemia. The association between hemospermia and hyperuricemia was examined by comparing such 22 hyperuricemic hemospermic patients with the other 21 idiopathic hemospermic patients.

RESULTS

The commonest 5 findings identified as possible causes of hemospermia were bilharziasis (21.6%), hyperuricemia (15.4%), idiopathic (14.7%), tuberculosis (8.4%), and chronic prostatitis (8.4%). Hyperuricemic hemospermic patients were significantly of younger age (median of 31.5 vs 45 years), complaining of more painful ejaculation (68.2% vs 9.5%), and had higher serum uric acid (median, 9.3 vs 4.5 mg/dL) compared with those of idiopathic hemospermia. Hemospermia disappeared completely in all patients of the hyperuricemia group vs only 25% of the idiopathic group (P <.001) within a mean of 2 months (range, 1-4 months).

CONCLUSION

Hyperuricemia is a new probable cause of hemospermia. Further randomized studies are mandatory for establishment of our postulation.

Hemospermia: long-term outcome in 165 patients

Long-term course of hemospermia has not been addressed in the sexual medicine literature. We report our 15 years' experience. From 1997 to 2012, 165 patients presented with hemospermia. Mean age was 38 years. Mean follow-up was 83 months. Laboratory evaluation and testis and transabdominal ultrasonography was done in all. Since 2008, all sonographies were done by the first author. One patient had urinary tuberculosis, one had bladder tumor and three had benign lesions at verumontanum. One patient had bilateral partial ejaculatory duct obstruction by stones. All six patients had persistent, frequently recurring or high-volume hemospermia. All pathologies were found in young patients. In the remaining 159 patients (96%), empiric treatment was given with a fluoroquinolone (Ciprofloxacin) plus an nonsteroidal anti-inflammatory drug (Celecoxib). In our 15 years of follow-up, no patient later developed life-threatening disease. Diagnostic evaluation of hemospermia is not worthwhile in the absolute majority of cases. Advanced age makes no difference. Only high-risk patients need to be evaluated. The vast majority of cases may be safely and effectively treated with empiric therapy. Almost all patients do well in long term.

Clinical analysis of the characterization of magnetic resonance imaging in 102 cases of refractory haematospermia

To analyze the pathogenesis of persistent and refractory haematospermia and to evaluate the aetiological diagnostic value of magnetic resonance imaging (MRI) for this type of haematospermia. Clinical data from 102 patients with persistent and refractory haematospermia was retrospectively analysed. Data collected included history, symptoms, as well as ultrasound and MRI of the morphological features of the bilateral seminal vesicles (SV) and ejaculatory duct (ED) areas. Criteria for inclusion were haematospermia symptoms that occurred more than six times, that lasted more than 6 months, and that did not improve after >1 month of conservative treatment. Patients underwent seminal vesiculoscopy with a post-surgery follow-up of 3-48 months [average (18.1 ± 10.3) months]. Of the 102 patients that underwent MRI examination, data from 88 patients (86.3%) showed typical and characteristic changes in the ED area, including the signal intensity changes in 60 (58.8%), SV volume changes in 32(31.4%), the formation of cysts such as prostatic utricular cysts in 27 (26.5%), Müllerian cysts in 4 (3.9%), ED cysts in 5 (4.9%) and a SV cyst in 1(1.0%). The MRI findings were confirmed by seminal vesiculoscopy and all patients received appropriate treatment. In 14 patients (13.7%), no obvious abnormal changes were observed with MRIs, however, these patients were diagnosed and successfully managed using seminal vesiculoscopy. Some degrees of ED obstruction was usually found during surgery. The symptoms of haematospermia disappeared 1-2 months after surgery in all patients. Two patients had a recurrence of haematospermia, underwent the same treatment, and recovered during the follow-up period. The aetiology of the most cases of the refractory haematospermia can be distinguished using the three-dimensional MRI. Typical abnormalities observed on MR images are signal intensity, SV volume changes and cyst formation. MRI has significant etiological diagnostic value and provides reliable information for the subsequent treatment of patients with persistent and refractory haematospermia.

Current status of 5α-reductase inhibitors in prostate disease management

The key enzyme in the androgen synthesis and androgen receptor pathways is 5α-reductase (5-AR), which occurs as three isoenzymes. Types I and II 5-ARs the most important clinically, and two different 5-AR inhibitors (5-ARIs), finasteride and dutasteride, have been developed. Several urology associations have recommended and upgraded the use of 5-ARIs for an enlarged prostate with lower urinary tract symptoms. In the Prostate Cancer Prevention Trial and the Reduction by Dutasteride of Prostate Cancer Events Trial, 5-ARIs reduced the incidence of low-grade prostate cancer. However, despite the documented reductions in the overall incidence of prostate cancer, 5-ARIs are at the center of a dispute. The American Society of Clinical Oncology (ASCO) and the American Urology Association (AUA) presented clinical guidelines for the use of 5-ARIs for chemoprevention of prostate cancer in 2008. However, ASCO/AUA has eliminated these from the main "Clinical Guidelines" in 2012, because the U.S. Food and Drug Administration denied a supplemental New Drug Application for the use of dutasteride for prostate cancer chemoprevention. The 5-ARIs can also be used to manage hemospermia and prostatic hematuria, and to prevent intraoperative bleeding, although there is insufficient evidence for a standard strategy. This review summarizes the current use of 5-ARIs for prostate disease, including benign prostate hyperplasia, prostate cancer, prostate-related bleeding, and hemospermia.

Prospective trial comparing transrectal ultrasonography and transurethral seminal vesiculoscopy for persistent hematospermia

OBJECTIVE

To compare the diagnostic yield of transrectal ultrasonography and transurethral seminal vesiculoscopy in patients with persistent hematospermia, and to determine the advantages and disadvantages of both modalities.

METHODS

We prospectively enrolled 106 patients with persistent hematospermia of mean duration 20.5 months. All patients were evaluated by both transrectal ultrasonography and transurethral seminal vesiculoscopy after excluding definite etiological lesions beyond the reproductive duct system. The diagnostic yield and other technical parameters of both modalities were compared.

RESULTS

Final diagnoses were made in 93 patients (87.7%), with transrectal ultrasonography and transurethral seminal vesiculoscopy showing overall diagnostic yields of 45.3% and 74.5%, respectively (P < 0.001). The diagnostic yield of combining transrectal ultrasonography and transurethral seminal vesiculoscopy was significantly higher than that of each modality alone (both P < 0.001). Of the 114 findings of diagnostic value, the most frequent was calculus (47.4%, n = 54), followed by obstruction/stricture (37.7%, n = 43), cyst (8.8%, n = 10), dysplasia (3.5%, n = 4), polyp (1.8%, n = 2) and benign mass (0.9%, n = 1). Transurethral seminal vesiculoscopy showed significant superiority in detecting calculi and obstruction/stricture. Hematospermia disappeared in 95.3% (101/106) of all patients and in 97.6% (83/85) of patients receiving transurethral seminal vesiculoscopy therapy during follow up. No major adverse effects occurred during and after examination.

CONCLUSIONS

The diagnostic yield of transurethral seminal vesiculoscopy for persistent hematospermia was significantly superior to that of transrectal ultrasonography, especially in lesions diagnosed with calculi and obstruction/stricture. Combining both modalities might provide extra benefits for patients with persistent hematospermia.