Гематоспермія

History of present illness should note the duration of symptoms. Patients who do not volunteer information should be asked specifically about a recent prostate biopsy or any trauma (eg, urologic instrumentation, penile injections, trauma related to sexual activity). Important associated symptoms include hematuria, difficulty starting or stopping urine flow, nocturia, burning with urination, and penile discharge. Association with sexual activity should also be noted.

Review of systems should seek symptoms of causative disorders, including easy bruising, frequent nosebleeds, and excessive gum bleeding with tooth brushing or dental procedures (hematologic disorders), and fevers, chills, night sweats, bone pain, or weight loss (prostate infection or cancer).

Past medical history should specifically ask about known disorders of the prostate, radiation treatment for prostate cancer, history of or exposure to tuberculosis (TB) or HIV, risk factors for sexually transmitted infections (STIs—eg, unprotected intercourse, multiple sex partners), known bleeding disorders, and known disorders that predispose to bleeding (eg, cirrhosis). Drug history should note use of anticoagulants or antiplatelet drugs. Patients should be asked about any family history of prostate cancer and travel to regions where schistosomiasis is endemic.

The external genitals should be inspected and palpated for signs of inflammation (erythema, mass, tenderness), particularly along the course of the epididymis. A digital rectal examination is done to examine the prostate for enlargement, tenderness, or a lump.

The following findings are of particular concern:

• Symptoms lasting > 1 month in the absence of a recent prostate biopsy

• Palpable lesion along the epididymis or in the prostate

• Travel to a region where schistosomiasis is prevalent

• Systemic symptoms (eg, fevers, weight loss, night sweats)

Patients whose symptoms followed prostate biopsy can be reassured that the hematospermia is harmless and will go away, although it often persists for several months.

Healthy, young patients with a brief duration of hematospermia, an otherwise normal history and examination, and no travel history likely have an idiopathic disorder.

Patients with abnormal findings on prostate examination may have prostate cancer, benign prostatic hyperplasia, or prostatitis. Urethral discharge suggests a sexually transmitted infection (STI).

Epididymal tenderness suggests an STI or rarely tuberculosis (more likely in patients with risk factors of exposure or who are immunocompromised).

Characteristic findings of a bleeding disorder or use of drugs that increase risk of bleeding suggests a precipitating cause but does not rule out an underlying disorder.

In most cases, especially in men < 35 to 40 years, hematospermia is almost always benign. If no significant abnormality is found on physical examination (including digital rectal examination), urinalysis, urine culture, and STI testing are done, but no further work-up is necessary.

Patients who may have a more serious underlying disorder and should have testing include those who have

• A longer duration of symptoms (> 1 month)

• Hematuria

• Obstructive urinary symptoms

• Abnormal examination findings

• Fevers, weight loss, or night sweats

These findings are of particular concern in men > 40 years. Testing includes urinalysis, urine culture, prostate-specific antigen (PSA) testing, and transrectal ultrasonography. Occasionally, MRI and cystoscopy are needed. Semen inspection and analysis are rarely done, but it can be useful when travel history suggests possible exposure to S. haematobium.