Patient's question:
What disease is it when there are chunks in the semen?Doctor's answer:
During sexual intercourse, when ejaculation or nocturnal emission occurs, red-colored semen is expelled. In traditional Chinese medicine, this condition is known as hematospermia. Normal semen appears milky white, grayish white, or pale yellow, while hematospermia appears pink, brownish red, or streaked with blood. Under a light microscope, red blood cells can be observed in the semen.When men experience hematospermia, they are often very frightened, believing that the discharge of blood with semen indicates a serious condition and may affect fertility, leading to infertility. In reality, this requires a case-by-case analysis.
### I. Factors or Causes of Hematospermia
Generally, hematospermia is not immediately noticeable unless there is significant bleeding. Otherwise, it is difficult to detect during intercourse. Even if blood stains are found on the penis or clothing after intercourse, people often first suspect factors related to the female partner. However, if intercourse is conducted with a condom or through coitus interruptus, hematospermia can be easily identified. When people suddenly notice a change in semen color, they often become anxious and speculate about what is happening.
When semen, which is normally milky white, suddenly turns blood-red, reddish-brown, or streaked with blood, it is clear that blood has been mixed in. But where does the blood come from? It must be from a pathological change in some part of the spermatic pathway, such as bleeding, inflammation, or even a tumor. Hematospermia should not be taken lightly, as it may also be a sign of a serious disease. It is best to consult a specialist doctor for a thorough examination. Clinically, hematospermia is not uncommon. After detailed clinical and laboratory tests, the majority of cases can be controlled or cured with treatment, though a small number of tumor patients may require further treatment.
The composition of semen consists mainly of a small volume of sperm and, to a greater extent, seminal vesicle fluid, followed by prostatic fluid. Anatomically, the ejaculatory ducts connecting the seminal vesicles open into the posterior urethra at the urethral crest, surrounded by 10–20 openings of prostatic ducts. In fact, the seminal vesicles, prostate, and posterior urethra are interconnected, and inflammation can easily spread from one to the others. Additionally, the wall of the seminal vesicle is very thin, and once congested, the blood-filled wall is prone to bleeding. Therefore, the most common cause of hematospermia is seminal vesiculitis, followed by prostatitis and posterior urethral inflammation or congestion. It can also be caused by inflammation spreading from nearby organs, leading to inflammation, swelling, congestion, and bleeding of the seminal vesicle wall. Generally, at least 70% of hematospermia cases in individuals under 30 are caused by inflammation.
If hematospermia occurs only occasionally and no specific abnormalities are found upon examination, it may be due to minor blood vessel rupture and bleeding caused by rapid congestion and mechanical trauma during intercourse. Such transient hematospermia requires no alarm, as complete recovery can be achieved by abstaining from sexual activity for one to two weeks. Hemorrhage caused by inflammation may fluctuate but does not last long. If hematospermia persists and worsens, the possibility of a tumor cannot be ruled out. Some patients may also have widespread bleeding tendencies in other parts of the body, which could indicate systemic hemorrhagic disorders such as leukemia or thrombocytopenia, rather than localized conditions.
Other causes include tuberculosis, seminal vesicle cysts, seminal vesicle tumors, prostate cancer, portal hypertension due to liver cirrhosis, trauma, urinary tract obstruction, and benign prostatic hyperplasia.
### II. Clinical Manifestations of Hematospermia
The infection pathways, causes, clinical manifestations, and symptoms of seminal vesiculitis and prostatitis are largely similar. They are mostly caused by bacterial infections or, in some cases, by frequent intercourse or prolonged abstinence, leading to congestion due to unrelieved sexual tension. Seminal vesiculitis is primarily characterized by hematospermia during intercourse, accompanied by reduced libido, premature ejaculation, mild perineal pain or fullness, painful ejaculation, frequent urination, and dysuria. Prostatitis is also accompanied by a burning sensation during urination, urinary urgency, incomplete voiding after urination, or the discharge of milky, viscous fluid from the urethral orifice after urination. It may also cause non-localized pain, premature ejaculation, nocturnal emissions, and erectile dysfunction.
Due to their complex anatomical structure and poor drainage, these conditions are prone to becoming chronic, leading to secondary obstruction of the vas deferens and edema or obstruction of the ejaculatory ducts, resulting in dry ejaculation (ejaculation without semen). This is the mechanism by which hematospermia causes infertility. Other factors contributing to infertility include changes in seminal fluid composition during seminal vesiculitis, where bacteria consume nutrients in the seminal fluid, compete for oxygen, and release toxins and metabolic byproducts, creating a highly unfavorable environment for sperm. During inflammation, the acidic substances in seminal fluid increase, lowering the pH from the normally alkaline range of 7.2–8.9 to below the minimum requirement for sperm survival (6–6.5), causing sperm to die prematurely and lose fertility. Additionally, during inflammation, the presence of a large number of cells, white blood cells, and even pus significantly increases the viscosity of the seminal fluid, making it difficult to liquefy and hindering sperm motility, preventing them from reaching the cervix. The volume of seminal fluid during inflammation is either too small, which is unfavorable for sperm survival, or too large, which dilutes the sperm and hinders fertility. These analyses are only superficial, as many factors remain unclear and require further research. In some cases, even with severe inflammation, fertility is not affected. However, if the ejaculatory duct remains blocked for a long time, it may lead to the development of antisperm antibodies in the body, complicating the issue further.
Seminal vesicle cysts are usually asymptomatic and are congenital conditions. Secondary seminal vesiculitis may cause hematospermia, which tends to recur. Large cysts may compress the bladder or urethra, causing urinary difficulties. For difficult-to-treat cases of hematospermia, percutaneous transurethral seminal vesicle injection with contrast material for X-ray imaging may reveal smooth-walled cystic masses in the seminal vesicles. B-mode ultrasound can detect these cystic masses. After contrast imaging, antibiotics can be directly injected into the cyst via a catheter. If this is ineffective, surgical removal of the cyst may be necessary. Seminal vesicle tumors are even rarer. B-mode ultrasound shows the mass as solid, while seminal vesicle contrast imaging reveals contrast material defects caused by tumor occupation of space. In such cases, surgical removal of the tumor is required.
Due to differences in bleeding location and volume, the appearance of hematospermia varies: blood from congested urethral mucosa during erection appears bright red and does not mix with semen, resembling streaks of blood. Hematospermia caused by inflammation or trauma appears uniformly red to coffee-colored, as the blood has had time to change color. Since the seminal fluid accumulated in the seminal vesicles is not fully expelled in a single ejaculation, even with timely and adequate treatment, hematospermia may persist for some time before disappearing.
### III. Diagnosis and Treatment
During clinical laboratory tests, when collecting secretion samples, attention should be paid to the relationship between the pressure area of the rectal examination and the secretions. Prostatic fluid should be collected first by massaging the prostate, followed by urination, and then massaging the left and right seminal vesicles to collect seminal fluid, which aids in differential diagnosis. Seminal vesicle contrast imaging may be performed if necessary to confirm the diagnosis. Laboratory tests can reveal a large number of red blood cells in the semen.
The treatment principles for hematospermia are generally the same (with special treatment required for tumors or tuberculosis). During acute bleeding, sexual activity should be avoided. Even after hematospermia disappears, rest for 1–2 weeks is recommended, and sexual activity should not be too frequent or intense afterward. Alcohol and spicy, irritating foods should be avoided to prevent further congestion. Long-distance cycling or horseback riding should be avoided. Weekly massage of the seminal vesicles and prostate helps expel inflammatory secretions. Daily hot sitz baths for 15–20 minutes at 41–42°C (a 30-day course followed by a 10-day rest before the next course) are beneficial. Antibiotics such as penicillin, gentamicin, or kanamycin (administered via muscle injection or local ion) and hemostatic agents like vitamin K or anluo blood are also necessary. Physical therapy and traditional Chinese medicine treatments can be used. If posterior urethralitis is present, posterior urethral medication instillation therapy may be applied. With proper treatment, recovery will not affect sexual activity or fertility, so there is no need to worry. However, caution is still required to avoid delaying treatment and compromising fertility.