Patient's question:
I am a middle-aged man, 40 years old this year. Due to irregular rest and physical exhaustion, I experienced blood discharge from the penis during sexual activity recently. What could be the reason? Thank you.Doctor's answer:
During sexual intercourse or nocturnal emissions, if red-colored semen is expelled, it is referred to as hematospermia in traditional Chinese medicine. Normal semen is milky white, grayish white, or pale yellow, but after hematospermia occurs, it appears pink, brownish red, or streaked with blood. Under an optical microscope, red blood cells can be observed in the semen. Men often become extremely frightened upon seeing hematospermia, believing that the discharge of blood with semen indicates a severe condition and that fertility will be significantly affected, potentially leading to infertility. In reality, this requires a case-by-case analysis.### I. 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-stained discharge is observed on the penis or clothing after intercourse, people often first suspect issues with the female partner. However, if intercourse is conducted with a condom or through coitus interruptus, hematospermia becomes easier to identify. When semen suddenly changes color, people often become anxious and speculate about the cause. The sudden shift from normal milky white semen to blood-red, reddish-brown, or blood-streaked semen clearly indicates the presence of blood. But where does the blood come from? It must originate from a pathological condition in some part of the spermatic pathway, such as bleeding, inflammation, or even a tumor. Hematospermia should not be taken lightly, as it may be a sign of a serious disease. It is best to consult a specialist for a thorough examination.
Clinically, hematospermia is not uncommon. After detailed clinical and laboratory examinations, 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, aside from the small volume of sperm, primarily comes 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 posterior urethral 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 under 30 years old 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. In such cases of transient hematospermia, there is no need to panic—resting from sexual activity for one to two weeks is usually sufficient for full recovery. 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 have widespread bleeding tendencies in other parts of the body, suggesting systemic hemorrhagic disorders like 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
Seminal vesiculitis and prostatitis share similar routes of infection, causes, clinical manifestations, and symptoms, mostly bacterial in origin. They can also result from frequent intercourse or prolonged abstinence, where sexual tension is not released, leading to organ congestion. Seminal vesiculitis primarily presents with 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, post-micturition dribbling, or a milky, viscous discharge from the urethral orifice after urination, along with non-localized pain, premature ejaculation, nocturnal emissions, and erectile dysfunction. Due to their complex anatomy and poor drainage, these conditions are prone to becoming chronic, potentially leading to secondary seminal vesicle obstruction, edema and obstruction of the ejaculatory duct, resulting in 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 to below the minimum requirement for sperm survival (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 semen and making it difficult to liquefy. As a result, sperm cannot move effectively to penetrate 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. In fact, many 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 antisperm 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 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 cystic lesions. 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 tumor occupation. In such cases, surgical removal of the tumor is required.
Due to differences in bleeding sites and volumes, the appearance of hematospermia varies: blood from congested urethral mucosa during erection appears bright red and mixed with semen like streaks of blood. Hematospermia caused by inflammation or trauma appears uniformly red to coffee-colored, as the blood has been stored for a while and has changed color. Since the semen stored 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. Diagnostic and Treatment Methods
Clinical laboratory tests require attention to the relationship between the rectal palpation area during secretion collection and the nature of the secretions. First, massage the prostate to collect prostatic fluid, then urinate and separately massage the left and right seminal vesicles to collect seminal vesicle fluid, which aids 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 generally similar (with special treatment required for tumors or 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 also be avoided. Weekly massage of the seminal vesicles and prostate helps expel inflammatory secretions. Daily hot Sitz baths (41–42°C for 15–20 minutes) for 30 days, followed by a 10-day rest before the next cycle, are beneficial. Antibiotics such as penicillin, gentamicin, or kanamycin (administered intramuscularly or via local ion) and hemostatic agents like vitamin K or anluo blood are also necessary for symptomatic treatment. Physical therapy and traditional Chinese medicine treatments can also be used. If posterior urethritis is present, medicationtherapy may 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.