Haemospermia

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • Tuberculosis
  • Schistosomiasis
  • Malignant Hypertension
  • Structural Problems (Such as Urethral Strictures or Polyps)

Ready Reckoner

Key distinguishing features of the most common diagnoses

UnknownProstatitisPost-opGU infectionTrauma
PersistentPossiblePossibleNoPossibleNo
Recent Surgical InterventionNoPossibleYesPossibleNo
Recent TraumaPossibleNoNoNoYes
Urinary Tract SymptomsNoPossiblePossibleYesNo
Prostate Markedly Tender on PRNoYesPossibleNoNo

Possible Investigations

Likely:Urinalysis, MSU.

Possible:FBC, ESR/CRP, PSA, urethral swab.

Small Print:INR, clotting screen, seminal fluid culture, transrectal ultrasound, prostate biopsy, urethroscopy.

  • Urinalysis: Protein, nitrites, leucocytes and possible haematuria in any genito-urinary infection or prostatitis. Haematuria possible in malignancy and schistosomiasis.
  • MSU: To confirm infection and identify pathogen.
  • FBC and ESR/CRP: WCC may be elevated in infection; Hb may be reduced and ESR/CRP raised in malignancy; ESR/CRP also raised in infection.
  • PSA: The pros and cons of this test might be discussed as a pointer to prostatic carcinoma.
  • Urethral swab: If urethritis suspected (best taken at GUM clinic).
  • INR, clotting screen: If patient on warfarin or a bleeding disorder suspected.
  • Other investigations (usually hospital-based): These might include seminal fluid culture to investigate deep-seated infection; transrectal ultrasound and prostatic biopsy for detailed investigation of prostate; urethroscopy/cystoscopy if felt to be a structural urethral or bladder problem.

Top Tips

  • A frank and open approach, using plain language, is important for the patient to feel comfortable and capable of describing an accurate history.
  • Do not underestimate the patient’s level of anxiety – and ensure it’s properly addressed. Most men with this symptom are convinced they have serious pathology.
  • The approach with this symptom has more to do with deciding on further action than establishing a precise diagnosis. This is because assessment in primary care rarely reveals any underlying pathology – management is more likely to be influenced by the patient’s age and the history than the clinical findings (see the following point).
  • Men under the age of 40 with short-lived symptoms do not require referral, as the chance of significant pathology is miniscule. Older men – and those with persistent or recurrent haemospermia, or abnormalities on initial assessment – require referral for further assessment.

Red Flags

  • A serious underlying cause is rare but should be considered in men over the age of 40 who have more than one episode.
  • The chances of significant pathology are increased by the finding of microscopic haematuria – refer these cases.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.