Excerpt from Hematospermia

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Background

While often perceived as a symptom of little significance, blood in the ejaculate can cause great concern to the men who experience it. The condition is common, and many episodes go unnoticed; therefore, the prevalence of hematospermia remains unknown. For most patients, no further diagnostic workup is needed; however, for some patients, hematospermia may be the first indicator of other urologic diseases.

Hematospermia has been written about for centuries. Hippocrates, Galen, Pare, Morgagni, and Fournier all commented on this condition. The first American report appeared in 1894, and Fletcher, Leary, Marshall, and Ganabathi have subsequently published excellent contemporary reviews. The advent of newer imaging modalities has altered both the diagnosis and the treatment of patients with this condition.

Pathophysiology

For an understanding of the causes of hematospermia, a working knowledge of the relevant anatomy of the ejaculatory complex is useful.

The seminal vesicles are androgen-dependent accessory organs that function in the production and storage of seminal fluid, which is essential to male fertility. The seminal vesicles are best studied ultrasonographically. Normal seminal vesicles are flat, paired structures that lie cephalad to the prostate behind the bladder and have a bow-tie appearance on transverse imaging. They are symmetric, well-defined, saccular, elongated organs. In its normal collapsed state, the center of the gland is homogenous, with areas of increased echogenicity corresponding to the folds of secretory epithelium. In the distended state, the wall can be seen to be composed of 2 distinct layers. Caudally, the seminal vesicles diverge laterally.

The dimensions of the seminal vesicles vary with age, but not with the ejaculatory state. Upon transrectal ultrasonography (TRUS), the dimensions are estimated to be 30 ± 5 mm in length, 15 ± 4 mm in width, and 13.7 ± 3.7 mL in mean volume. The age of the patient and degree of prostate enlargement have been shown to cause variation in the size of the seminal vesicles.

MRI findings may also help delineate the normal anatomy of the seminal vesicles. Using MRI, the signal intensity of the seminal vesicles can be compared with the tissues surrounding them (ie, skeletal muscle, fat, urine). The signal intensity on T1-weighted spin-echo images of normal seminal vesicles in men is similar to or slightly higher than that of skeletal muscles and is always greater than that of urine. On T2-weighted images, the signal intensity is variable. Prepubertally and in men older than 70 years (androgen-deprived males), the signal intensity is generally lower than that of skeletal muscle or urine. Convolutions of the seminal vesicles are best observed on T2-weighted images or on T1-weighted images with the use of intravenous contrast agents.

The vasa deferentia act as conduits, carrying sperm between the epididymis and the ejaculatory ducts via the vasal ampullae. The vasal ampullae pass medially to the seminal vesicles and are best seen using transaxial TRUS views.

The seminal vesicles and vasal ampullae join together to form the ejaculatory duct. The ejaculatory duct travels through the prostate and enters the urethra at the level of the verumontanum. The junction between the seminal vesicle and the ejaculatory duct lies within the prostate and is difficult to see in a healthy unobstructed system. Small echodensities are frequently seen at the junction of the ejaculatory ducts and the verumontanum in the urethra. These areas provide useful landmarks and are thought to represent concretions within the periurethral glands surrounding the verumontanum.

Frequency

United States

True prevalence is unknown because most ejaculations occur intravaginally and hematospermia often remains unrecognized.

Recent data collected after TRUS-guided biopsy of the prostate suggest that up to 36.3% of men undergoing 6-15 cores develop postprocedure hematospermia. Increasing the number of cores did not significantly increase the frequency of hematospermia (Berger, 2004).

Sex

Hematospermia affects males.

Age

This condition can occur in persons of any age. In younger men ( <40 y), it is uniformly benign. In older men, it is rarely associated with malignancy.

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