Patient's question:
Currently, in general: Blood in semen during sexual intercourse Medical history: No previous discoveryDoctor's answer:
I. Causes of HematospermiaGenerally speaking, hematospermia is not immediately noticeable unless there is significant bleeding. It is often difficult to detect during intercourse unless the semen appears bloody, in which case people may first suspect issues with the female partner. If using condoms or practicing withdrawal ejaculation, hematospermia becomes more apparent. When semen color suddenly changes, it can cause anxiety, leading to restless speculation about what is happening. The semen, which is normally milky white, may turn bright red, reddish-brown, or mixed with blood streaks, indicating the presence of blood. Where does this blood come from? It is likely due to pathological changes in some part of the spermatic pathway, such as bleeding, inflammation, or even tumors. Hematospermia should not be taken lightly, as it may signal a serious underlying condition. It is best to consult a specialist doctor for a thorough examination.
Clinically, hematospermia is not uncommon. With detailed clinical and laboratory tests, the majority of cases can be controlled or cured through treatment, though a small number of tumor patients may require further intervention. The composition of semen consists mainly of a small volume of sperm, with the rest derived from the seminal vesicles, followed by the prostate. 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, making it easy for inflammation to 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, posterior urethritis, or congestion of the posterior urethra. 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 under the age of 30 are due to inflammation. If hematospermia occurs only occasionally and no specific abnormalities are found during examination, it may be due to minor blood vessel rupture and bleeding in certain tissues during intercourse caused by rapid congestion and mechanical friction. This type of transient hematospermia does not require alarm, as complete recovery can be achieved with a brief pause in sexual activity for one to two weeks. Hemorrhage caused by inflammation tends to fluctuate but does not last long. If hematospermia persists and worsens, the possibility of a tumor should not be ruled out. Some patients may also exhibit widespread bleeding tendencies in other parts of the body, suggesting 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, etiology, 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 of the organs. Seminal vesiculitis primarily presents with hematospermia during intercourse, accompanied by reduced libido, premature ejaculation, mild perineal pain or a sense of fullness, painful ejaculation, frequent urination, and dysuria. Prostatitis is also associated with a burning sensation during urination, urinary urgency, incomplete urination after voiding, or the presence of milky, viscous fluid at the urethral orifice after urination. It may also cause non-localized pain, as well as sexual dysfunctions such as premature ejaculation, nocturnal emissions, and weak erections. Due to their complex anatomy and poor drainage, these conditions are prone to becoming chronic, leading to secondary obstruction of the vas deferens, edema and obstruction of the ejaculatory ducts, and dry ejaculation (ejaculation without semen). This is the mechanism by which hematospermia causes infertility. Other causes of infertility include changes in seminal plasma composition during seminal vesiculitis, where bacteria consume nutrients, compete for oxygen, and release toxins and metabolic byproducts, creating a highly unfavorable environment for sperm and reducing fertility. During inflammation, the acidic substances in seminal plasma increase, lowering the pH from the normally alkaline range of 7.2–8.9 suitable for sperm survival to below the minimum requirement of 6–6.5, causing sperm to die prematurely and lose fertility. Inflammation also increases the number of cells and white blood cells in seminal plasma, sometimes mixed with pus, significantly thickening the fluid and making it difficult to liquefy after ejaculation. This hinders sperm motility, preventing them from reaching the cervix. The volume of seminal plasma 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 aspects or causes remain unclear and require further research. It is worth noting that some patients with severe inflammation do not experience fertility issues. However, if the ejaculatory duct remains blocked for a long time, it may lead to the development of anti-sperm antibodies in the body, complicating the situation further. Seminal vesicle cysts are usually asymptomatic and congenital. Secondary seminal vesiculitis may cause hematospermia, which tends to recur. Large cysts may also compress the bladder and urethra, causing urinary difficulties. For difficult-to-treat cases of hematospermia, percutaneous transurethral injection of contrast material followed by X-ray imaging can 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 ineffective, surgical removal of the cyst may be necessary. Seminal vesicle tumors are even rarer. B-mode ultrasound shows the tumor as solid, while seminal vesicle contrast imaging reveals contrast material defects caused by the tumor occupying space. In such cases, surgical removal of the tumor is required.
The appearance of hematospermia varies depending on the bleeding location and volume. 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 uniform and reddish-brown, as the blood changes color over time. Since the semen 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 resolving.
III. Diagnosis and Treatment
Clinical laboratory tests require attention to the relationship between the rectal palpation area during secretion collection 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 vesicle fluid. This helps in differential diagnosis. If necessary, seminal vesicle contrast imaging can be performed for definitive diagnosis. Laboratory tests may reveal a high number of red blood cells in the semen.
The treatment principles for hematospermia are similar (with special treatment required for tumors and tuberculosis). During acute bleeding, sexual activity should be avoided. Even after hematospermia resolves, 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 (41–42°C, 15–20 minutes each) for 30 days, followed by a 10-day rest period before the next cycle, are beneficial. Antibiotics such as penicillin, gentamicin, and kanamycin (administered via muscle injection or local ion) and hemostatic agents like vitamin K and anluo blood are also necessary for symptomatic treatment. Physical therapy and traditional Chinese medicine treatments can also be used. If posterior urethritis is present, medication therapy can be applied.
With proper treatment, recovery will not affect sexual activity or fertility, so there is no need to worry. However, it is important not to be complacent, as delayed treatment may lead to fertility issues.