Changes

September 2026 — reviewed. A literature search was conducted in July 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. There have been minor structural changes to the topic, including the addition of sections summarizing risk factors and complications of haematospermia. Minor additions and clarifications have also been added to align the recommendations with recent guidelines and expert opinion review articles.

Update

Goals

To support primary healthcare professionals to:

• Carry out a thorough clinical assessment to determine the cause of haematospermia.
• Manage the cause of haematospermia in primary care if appropriate.
• Appropriately refer for specialist investigation and management.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE Quality standards

No NICE Quality standards were found during the review of this topic.

What is haematospermia?

• Haematospermia is the presence of blood in seminal fluid.
  • Blood may be visible or identified incidentally (for example, in semen analysis during fertility investigations).
  • The blood appears bright red (with or without clots) when bleeding has occurred recently and darker red/brown if older.
• Haematospermia can occur as a single episode, or repeatedly over time.

[Gallagher, 2019; Drury, 2022; Harmath, 2025; EAU, 2025]

How common is it?

• The precise incidence and prevalence of haematospermia are unknown due to a number of factors. This includes covert presentation, its usually self-limiting nature, and in some cases, patient reluctance to seek medical review.
  • A US study using nationally representative data from a health insurance claims database estimated the 2018 average incidence of haematospermia at 73.6 per 100,000 males, with the incidence increasing from 27.6 per 100,000 males aged 18 to 24 years to 111.9  per 100,000 males aged 55 to 64 years [Hakam, 2022].
• It is estimated that between 1–1.5% of urological referrals are made due to haematospermia.
• Haematospermia is thought to be most common in men younger than 40 years of age.
  • Two studies found that the mean age at presentation was 37 years [Mulhall, 1995; Ng, 2013].

[Dantanarayana, 2015; Parnham, 2016; Harmath, 2025]

What causes it?

• Haematospermia may be associated with pathology of the prostate gland, seminal tract (seminal vesicles, vasa deferentia, and ejaculatory ducts), verumontanum, urethra, urinary bladder, epididymis, testes, or accessory glands such as Cowper glands.
• The most common causes are:
  • Iatrogenic, for example, following a recent urological procedure such as prostate biopsy or radiotherapy, cystoscopy, or vasectomy.
  • Urogenital infection (the most common cause in men under 40 years of age), including:
    • Sexually transmitted infections such as chlamydia, gonorrhoea, and herpes simplex.
    • Organisms associated with urinary tract infection such as Escherichia coli, Proteus mirabilis, Ureaplasma urealyticum, and Enterobacter.
    • Rarer infective causes, such as tuberculosis and schistosomiasis.
• Other causes include:
  • Trauma, for example, coital trauma or injury of the pelvis, perineum, or genitals.
  • Malignant tumours of the prostate, bladder, urethra, testes/epididymis, or seminal vesicles.
  • Prostatic conditions such as acute/chronic prostatitis, benign prostatic hyperplasia, prostatic calculi, and prostatic cysts.
  • Testicular or epididymal conditions such as orchitis or epididymitis.
  • Seminal vesicle/ejaculatory duct conditions such as cysts or calculi, seminal vesiculitis, or ductal obstruction. Improved imaging techniques have confirmed that one of the main sites of bleeding is the seminal vesicles.
  • Systemic disorders such as severe uncontrolled hypertension, bleeding disorders, lymphoma, leukaemia, amyloidosis, and severe liver disease.
  • Medications such as anticoagulants, antiplatelets, 5-alpha reductase inhibitors (finasteride and dutasteride), and panitumumab.
  • Congenital malformations (rare — examples include vascular malformations, midline prostatic cyst, and Zinner syndrome).
• Most cases of haematospermia have a benign cause. 
• In men younger than 40 years of age:
  • The most common cause is infection (urinary tract infection or sexually transmitted infection).
• In men of 40 years of age or older:
  • Malignancy is a more common cause of haematospermia than in men under 40 years old.
  • Several studies have demonstrated an association between haematospermia in men aged 40 years or older and urologic malignancy, with the incidence ranging from 0.11% to 6.2% [Harmath, 2025].
  • A US study using nationally representative data from a health insurance claims database identified only 47 cases where a urologic cancer was subsequently diagnosed among 55,717 patients presenting with benign haematospermia. The median age at diagnosis was 56 years (interquartile range 52 to 61 years), and only one case of cancer (testicular) was observed among 15,106 aged 40 years or under [Hakam, 2022].
• An observational study of 300 men with haematospermia found that, in men younger than 40 years versus those older than 40 years [Ng, 2013]:
  • Malignancy was the cause in 1.4% versus 6.2%.
  • Urinary tract infection was the cause in 15% versus 10.3%.
  • Calculi were the cause in 1.4% versus 2.2%.
• Despite the wide range of possible aetiologies for haematospermia, it is very common for investigations to find no identifiable cause.

[Dantanarayana, 2015; Gallagher, 2019; Madhushankha, 2021; Drury, 2022; Efesoy, 2022; Hakam, 2022; Satchi, 2022; EAU, 2025; Harmath, 2025]

What are the risk factors?

• Risk factors for haematospermia relate to the potential underlying cause. These include:
  • Age — haematospermia is most commonly seen in younger men, but an age of 40 years or greater is an important risk factor for malignancy, particularly if haematospermia is persistent or recurrent.
  • Recent urological procedures, such as a prostate biopsy, cystoscopy, or vasectomy.
  • Risk factors for sexually transmitted infection (STI), such as multiple or new sexual partners, inconsistent or unprotected condom use, sex work, intravenous drug use, or having a sexual partner with known risk factors for STI.
  • History of travel to tropical countries, particularly those where tuberculosis or schistosomiasis are endemic, such as Africa, Southern and South-East Asia, tropical regions of South America, and the Western Pacific.
  • Bleeding disorders, increased bleeding tendency, or use of anticoagulant or antiplatelet medicines.
  • Recent sexual activity, particularly vigorous sexual intercourse or masturbation, or prolonged sexual abstinence.
  • Local genital, perineal, or pelvic trauma.
  • Previous or current genitourinary disease.

[Gallagher, 2019; Efesoy, 2022; Satchi, 2022; EAU, 2025]

What is the prognosis?

• Most cases of haematospermia are benign and self-limiting.
• A study of 189 Japanese men with haematospermia not caused by inflammation, infection, or malignancy found that [Furuya, 2016]:
  • Haematospermia resolved spontaneously in 88.9% of men.
  • The median duration was 1.5 months.
  • The persistence rates of haematospermia were 57.7% at 1 month, 34.2% at 3 months, 23.3% at 6 months, 12.5% at 1 year and 7.6% at 2 years.
  • Haematospermia reoccurred in 20 (13.5%) of the 148 men who had adequate follow up. The recurrence-free rates were 96.6% at 3 months, 89.0% at 1 year, 84.8% at 5 years and 78.2% at 10 years.
• Recurrent or persistent haematospermia, and/or specific associated symptoms increase the chance of malignancy as an underlying pathology.  For further information, see the section How should I assess a person with haematospermia?
• The majority of men referred to urology for further assessment do not have an underlying cancer.

[Madhushankha, 2021; Drury, 2022; Harmath, 2025]

What are the complications?

• Haematospermia is usually a benign and self-limiting condition. When not associated with a significant underlying pathology, the main complications include:
  • Anxiety and psychological distress — haematospermia can cause significant fear and anxiety, and it is common for people to associate it with malignancy or a sexually transmitted infection (STI).
  • Impact on sexual health and relationships — sexual partners may be repulsed by the sight of blood in the ejaculate or concerned that it may indicate an STI.
  • Associated genitourinary symptoms, including haematuria; dysuria; and pelvic, perineal, or scrotal pain.
• Haematospermia itself is not generally considered a cause of male infertility, but some causes of haematospermia, such as genitourinary infection, inflammation or obstruction of the reproductive tract, may impair male fertility.

[Gallagher, 2019; Drury, 2022; Satchi, 2022; Harmath, 2025]

How should I assess a person with haematospermia?

• Note the person's age. Men older than 40 years of age with haematospermia are at increased risk of a serious underlying cause.
• Ask about:
  • The duration and frequency of haematospermia.
    • Prolonged and/or recurrent episodes increase the risk of a serious underlying cause.
  • The colour of the semen.
    • Bright red (with or without clots) indicates fresh bleeding, while older blood may appear brown.
  • The amount of blood and the scenarios where haematospermia has been observed (coitus or masturbation).
    • Exclude pseudo-haematospermia. Determine if sexual activity around the time haematospermia presented coincided with a partner’s menstrual cycle, or could have occurred due to any other external source. Other causes of pseudo-haematospermia include haematuria, which should be excluded.
  • Physical injuries to the pelvic or groin area.
  • Associated symptoms.
    • Symptoms that can indicate a urinary tract infection include dysuria; frequency; urgency; visible haematuria; and pain in the abdomen, scrotum, pelvis, or perineum. For further information, see the CKS topics on Urinary tract infection (lower) - men and Urinary tract infection - children.
    • Perineal, penile, rectal or suprapubic pain associated with symptoms of a urinary tract infection may indicate acute or chronic prostatitis. For further information, see the CKS topics on Prostatitis - acute and Prostatitis - chronic.
    • Painless haematuria may indicate an underlying urological cancer. For further information, see the CKS topic on Urological cancers - recognition and referral.
    • The presence of urethral discharge may indicate a sexually transmitted infection. For further information, see the CKS topics on Chlamydia - uncomplicated genital, Urethritis - male, Gonorrhoea, Trichomoniasis, and Herpes simplex - genital.
    • Urinary hesitancy, frequency, or dribbling may indicate benign prostatic hypertrophy or prostate cancer. For further information, see the CKS topics on LUTS in men and Prostate cancer.
    • Unilateral testicular enlargement, swelling, change in shape or discomfort may indicate a testicular cancer. Systemic symptoms such as weight loss, loss of appetite or bone pain could also indicate malignancy. For further information, see the CKS topics on Scrotal pain and swelling and Urological cancers - recognition and referral.
  • Recent urological investigations or interventions.
  • Past medical history including hypertension, prolonged or excessive bleeding, easy bruising from minor injuries or surgical procedures, or personal or family history of coagulopathy.
  • Sexual history including risk of sexually transmitted infections.
  • Travel history, particularly to areas where tuberculosis and schistosomiasis are endemic.
  • Medication, including anticoagulants, antiplatelets, 5-alpha reductase inhibitors, and panitumumab.
• Examine the person:
  • Measure blood pressure for signs of uncontrolled hypertension and temperature to check for fever.
  • Palpate the abdomen (to identify masses such as hepatosplenomegaly, which could indicate an underlying haematological, hepatic, or infectious disease) and local lymph nodes (looking for lymphadenopathy).
  • Examine the urethral meatus looking for trauma, discharge and skin lesions. Palpate the testes to detect lumps, scrotal tenderness, or swelling. For further information, see the CKS topic on Scrotal pain and swelling.
  • Consider performing a digital rectal examination to detect prostatic enlargement, tenderness, fluctuance, firmness, or nodules.
    • Use clinical judgement to determine whether this is necessary, taking into account factors such as the person's age, family history of prostate cancer (particularly in first-degree relatives), and ethnicity (incidence of prostate cancer is higher in men of black ethnicity).
    • For more information, see the CKS topic on Prostate cancer.
  • Look for signs of easy bruising or bleeding tendencies, such as petechiae and large bruises in the absence of trauma
• Carry out a urinalysis and send a mid-stream urine sample for culture and analysis in all people with haematospermia.
• Measure prostate-specific antigen (PSA) level in all men aged over 40 years and men of any age with signs and symptoms, or a family history of prostate cancer.
  • For further information, see the CKS topic on Prostate cancer.
• Consider other investigations guided by clinical findings, including:
  • A full blood count, coagulation screen, and renal and liver function tests.
  • Semen microscopy, culture and sensitivity if infection (for example, tuberculosis or schistosomiasis) is suspected.
  • Scrotal ultrasound if there is testicular swelling or discomfort. For further information, see the CKS topics on Scrotal pain and swelling and Urological cancers - recognition and referral.

Scenario: Management of a person with haematospermia

From age 12 years onwards (Male).

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of haematospermia, with additional searches for evidence in the following areas:

• Risk of sexually transmitted disease

Search dates

January 2022 - September 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp Hemospermia/, haemospermia.tw, hematospermia.tw, haematospermia.tw, HS.ti,ab. exp Genital Diseases, Male/
• exp Sexually Transmitted Diseases/, STI.tw., STD.tw., sexually transmitted infection.tw., sexually transmitted disease.tw.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.