Bloody semen. Is it a serious problem?

Is it normal that the blood in the semen changes its colour?

Over several weeks, it can range from fresh blood to rusty or brownish red (old blood).

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If you see blood in the semen, this is known as haematospermia. While it can be a worrying symptom, it is often not a cause for severe alert.

men of any age, but the 30- to 40-year-old age group is the typical presenting age.

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What causes blood in the ejaculation fluid?

There are many possible causes of blood in the semen:

1. Inflammation or infection of the prostate gland (prostatitis) or seminal vesicles can cause haematospermia. These conditions can be treated with a course of antibiotics.
2. Urinary tract infection (UTI). The NHS consultant or private urologist will assess your waterwork habits. If a UTI is suspected, a urine culture is commonly sent to determine the type of bacterial infection, and an antibiotic course is prescribed. In men, difficulty emptying their bladders must be excluded as the underlying cause.
3. Trauma: Injury to the genitals, prostate gland, or urethra can cause haematospermia. This can occur during sexual activity, cycling, or other physical activities.
4. Benign enlargement of the prostate gland (BPE) or benign prostatic hyperplasia (BPH) lead to a higher density of blood vessels around the bladder neck area. These blood vessels are fragile that bleed easily.
5. Sexually transmitted infections (STIs) such as chlamydia or gonorrhoea. Typically in younger men.
6. Blood-thinning medications: like warfarin, rivaroxaban, apixaban, edoxaban, dabigatran, aspirin, clopidogrel, and dipyridamole.
7. Recent procedures include vasectomy (cutting the vas deferens for male sterilisation), transurethral resection of the prostate (TURP), prostate biopsy and flexible cystoscopy.
8. Less common causes include prostate cancer, bladder cancer, seminal vesicle stones, and clots in the seminal ducts.
9. Other medical conditions: severe uncontrolled high blood pressure, blood clotting disorders like sickle cell disease,
   

What is the most common cause of blood in semen?

The most typical cause of blood in semen is inflammation of the prostate gland - known as prostatitis.

Is blood in semen a sign of prostate cancer?

Although blood in the semen, medically referred to as haematospermia, can indicate prostate cancer, this is uncommon. In men over 50 years or those aged 45 years with risk factors for prostate cancer, if they experience blood in the semen, prostate cancer should be excluded. The doctor inserts the finger through the back passage to feel the gland, assesses for benign growth, and orders a PSA for an in-depth assessment.

Always visit your GP if you see blood with your semen

If you notice blood in your semen, always seek a GP review.

Frequently asked questions by your doctor

• number of times you have seen blood in your semen
• if there were any other symptoms (painful urination, fever, swelling, discomfort)
• any medical history
• any medical treatment
• any past surgical history
• any history of sexually transmitted infection
• any recent history of travel to a place where tuberculosis (TB) or schistosomiasis is endemic

What tests are carried out for blood when you orgasm

• blood pressure check
• an examination of your genitals and tummy (abdomen)
• a rectal exam to feel the prostate
• urine test
• Blood tests (FBC, renal profile, clotting profile (if indicated) and prostate-specific antigen (PSA if indicated)
  

When should I see an NHS Urology Consultant or Private Urologist?

If you're over 40 years old, have recurrent blood in semen, or the physical examination or the tests performed by GP come abnormal, you should be referred to a urologist.

In many cases, particularly if you have no other symptoms or the blood in your semen was an isolated incident, no treatment is necessary. The problem will usually resolve on its own.

What is the treatment for blood in ejaculatory fluid?

Haematospermia is often self-limiting, and most patients do not warrant any treatment.

Examples of treatment;

1. If bleeding comes from the bladder neck due to an enlarged prostate, one is prescribed a 5-Alpha reductase inhibitor (finasteride/dutasteride) for a year. These medications reduce to some extent the size of the huge prostate glands and, to a certain degree, in some cases, stop it from growing larger. They take a long time to start being effective, typically 9 to 12 months. If you check your blood test PSA and are on one of these medications, you must double it to get the result. 1% of men may complain of breast tenderness and enlargement, which needs to be stopped. In around 5% of men, it can cause erectile dysfunction.
2. Where an underlying infection is a culprit, antibiotics are prescribed.
3. If the doctor suspects prostatitis, they may give you anti-inflammatory drugs, antibiotics and medications to empty the bladder better like tamsulosin.

What further tests may be requested?

If you are suffering from repeated episodes of blood in the semen, your urologist may order the following tests to determine the exact cause;

• Magnetic Resonance Imaging (MRI) of the prostate (to exclude prostate cancer, stones in the prostate, and ejaculatory duct obstruction)
• Ultrasound scan of kidneys & bladder (to exclude stones and cancer)
• Transrectal ultrasound scan of your prostate (to identify prostate calcification and cancer, determine the size and ejaculatory duct obstruction)
• Ultrasound of your scrotum (exclude any testicular pathology)
• Flexible cystoscopy, a camera test to examine the urethra (water pipe), prostate and bladder is indicated if the risk factors for bladder cancer are high.

What is ejaculatory duct obstruction?

Radiologically, ejaculatory duct obstruction is defined if the seminal vesicle is >1.5cm wide or the ejaculatory duct is >2.3mm wide.

MRI has shown blood clots in the seminal vesicles; what is the treatment for this?

In those found to have swollen seminal vesicles, the presence of calculi or blood clots within the seminal vesicles or ejaculatory ducts is a common cause and washout of the seminal vesicles can be performed.

If there is ejaculatory duct obstruction, a resection of the ejaculatory ducts can also be performed.

How is washing of the tubes performed?

Passing a fine camera (6F or 7F ureteroscope) through the urethra (water pipe) under general anaesthetic to gain access to the ejaculatory ducts and seminal vesicles, the surgeon can perform a washout to small stones, blood clots and debris.

Reflection from a consultant urologist

Blood in your semen is a benign, self-limiting condition and, in most cases, is due to inflammation, infection, or other medical conditions.

A single episode in men younger than 40 should warrant no concern. Clinical history is vital to direct investigations and appropriate treatment based on the cause.

The reported prostate cancer detection rate is up to 7% in patients ≥40 years old. This means genital and rectal examination and prostate imaging in persistent blood in the semen are recommended.

Those patients with recurrent blood in semen, over 40 years old, high PSA or abnormal feeling prostate or risk factors for prostate cancer should be referred.