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the meatus re-examined after DRE for bloody discharge [910]. Detection of a palpable nodule in the prostate
is important because an association between haemospermia and PCa has been postulated although not
completely proven.

Magnetic resonance imaging is being increasingly used as a definitive means to investigate haemospermia. The
multiplanar ability of MRI to accurately represent structural changes in the prostate, seminal vesicles, ampulla
of vas deferens, and ejaculatory ducts has enabled the technique to be particularly useful in determining the
origin of midline or paramedian prostatic cysts and in determining optimal surgical management [911]. The
addition of an endorectal coil can improve the diagnostic accuracy for identifying the site and possible causes
of haemorrhage [912].

Cystoscopy has been included in most suggested investigative protocols in patients with high-risk features
(patients who are refractory to conservative treatment and who have persistent haemospermia). It can provide
invaluable information as it allows direct visualisation of the main structures in the urinary tract that can be
attributed to causes of haemospermia, such as: polyps, urethritis, prostatic cysts, foreign bodies, calcifications
and vascular abnormalities [913, 914].

With the advancement of optics, the ability to create ureteroscopes of diameters small enough to allow
insertion into the ejaculatory duct and seminal vesicles has been made possible [915]. In a prospective study,
106 patients with prolonged haemospermia underwent transrectal US and seminal vesiculoscopy. With both
methods combined, diagnosis was made in 87.7% of patients. When compared head-to-head, the diagnostic
yield for TRUS vs. seminal vesiculoscopy was 45.3% and 74.5%, respectively (P < 0.001) [916].

Melanospermia is a consequence of malignant melanoma involving the genitourinary tract and is a rare
condition that has been described in two case reports [917, 918]. Chromatography of the semen sample can
be used to distinguish the two by identifying the presence of melanin if needed.

6.8.4 Disease management
Conservative management is generally the primary treatment option when the patients are aged < 40 years and
have a single episode of haemospermia. The primary goal of treatment is to exclude malignant conditions like
prostate and bladder cancer and treat any other underlying cause. If no pathology is found, then the patient
can be reassured [224, 902].

Patients with recurrent haemospermia and who are middle-aged, warrant more aggressive intervention.
Appropriate antibiotic therapy should be given to patients who have urogenital infections or STIs. Urethral or
prostate varices or angiodyplastic vessels can be fulgurated, whereas cysts, either of the seminal vesicles or
prostatic urethra, can be aspirated transrectally [224]. Ejaculatory duct obstruction is managed by transurethral
incision at the duct opening [919, 920]. Systemic conditions should be treated appropriately [903, 906, 921, 922].
Defining a management algorithm for haemospermia is based on the patient age and degree of
haemospermia. Patients often find blood in the ejaculate alarming, and investigations should be aimed at
excluding a serious, despite infrequent, underlying cause (e.g., cancer), while at the same time preventing over-
investigation and alleviating patient anxiety. The literature describes a multitude of causes for haemospermia,
although many of these are not commonly found after investigation. However, men may be stratified
into higher-risk groups according to several factors including: age > 40 years, recurrent or persistent
haemospermia, actual risk for PCa (e.g., positive family history), and concurrent haematuria. Based upon the
literature, a management algorithm is proposed (Figure 9) [903, 906, 921, 922].

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