Semen is red, how to treat?

Patient's question:

Male, 43 years old, six months ago, semen was red, intravenous infusion for one week. The day before yesterday, for unknown reasons, semen turned red again. How should the treatment be effective?

Doctor's answer:

I. Causes of Hematospermia
Generally 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, people often become anxious and speculate about the cause. 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 the tissues along the spermatic pathway, such as bleeding, inflammation, or even tumors. Hematospermia should not be taken lightly, as it may be a sign of a serious underlying condition. It is best to consult a specialist 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 intervention. The composition of semen consists mainly of a small volume of sperm and primarily fluid 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 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 occasionally and no specific abnormalities are found during examination, it may be due to minor blood vessel rupture and bleeding caused by rapid congestion and mechanical trauma during intercourse. This type of transient hematospermia does not require alarm, as it usually resolves completely within one to two weeks of abstaining from sexual activity. Inflammation-related bleeding, however, 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 generalized 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, frequent intercourse or prolonged abstinence, leading to congestion of the organs. Seminal vesiculitis is primarily characterized by hematospermia during intercourse, accompanied by reduced libido, premature ejaculation, mild perineal pain or discomfort, painful ejaculation, frequent urination, and dysuria. Prostatitis may also cause a burning sensation during urination, urinary urgency, post-micturition dribbling, or the discharge of milky fluid from the urethral orifice after urination. It may also lead to 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 causing secondary obstruction of the vas deferens, edema and obstruction of the ejaculatory duct, and anejaculation (dry ejaculation) despite intercourse. This is the mechanism by which hematospermia leads to infertility. Other causes of infertility include changes in seminal fluid 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 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. Inflammation also increases the number of cells, white blood cells, and pus in the seminal fluid, significantly thickening it and making it difficult to liquefy. This hinders 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 sperm and reduces 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 issue 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 lesions. After contrast administration, antibiotics can be directly injected into the cyst via a catheter. If ineffective, surgical resection of the cyst may be necessary. Seminal vesicle tumors are even rarer. B-mode ultrasound shows solid tumors, while seminal vesicle contrast imaging reveals contrast-filled defects caused by tumor expansion. In such cases, surgical removal of the tumor is recommended.
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 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 resolving.
III. Diagnosis and Treatment
Clinical laboratory tests require attention to the relationship between the rectal palpation area during secretion collection and the secretions. First, massage the prostate to collect prostatic fluid, then urinate and separately massage 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 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) for 15–20 minutes (30-day cycles with 10-day rest periods between) are beneficial. Antibiotics such as penicillin, gentamicin, and kanamycin (administered via muscle injection or local ion) and hemostatic agents like vitamin K and anisodamine are also essential for symptomatic treatment. Physical therapy and traditional Chinese medicine treatments can also be used. If posterior urethritis is present, medication 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 necessary to avoid delaying treatment and compromising fertility.