Hematospermia is defined as blood in the semen. While often perceived as having little significance, blood in the ejaculate can cause great concern to the men who experience it. The condition is common, with many episodes going unnoticed; therefore, the prevalence of hematospermia remains unknown.
Hematospermia is most commonly secondary to infectious or inflammatory etiology and follows a benign and self-limited course.  As such, no further diagnostic workup is generally needed; however, in some patients, hematospermia may be the first indicator of other urologic diseases or systemic disorders (see DDx/Diagnostic Considerations).
The advent of newer imaging modalities, especially transrectal ultrasonography, has altered both the diagnosis and the treatment of hematospermia. In 2009, Aslam et al developed an algorithm to guide the management of these patients. 
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 published excellent contemporary reviews on the subject.
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 produce and store 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 seminal vesicle is homogeneous, with areas of increased echogenicity corresponding to the folds of secretory epithelium. In the distended state, the wall is visibly composed of 2 distinct layers.
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.
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.
The true prevalence of hematospermia is unknown. It is likely that many cases escape the patient’s notice, and remain unrecognized and unreported.
Data collected after TRUS-guided biopsy of the prostate suggest that up to 36.3% of men undergoing removal of 6-15 cores develop postprocedure hematospermia. Increasing the number of cores did not significantly increase the frequency of hematospermia.  Other studies have found rates of hematospermia following TRUS-guided biopsy to be as high as 84%. 
Hematospermia can occur in males of any age. In younger men (<40 y), hematospermia is uniformly benign. Even in older men, it is rarely associated with malignancy.
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Alexander D Tapper, MD Resident Physician, Department of Urology, William Beaumont Hospital
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, Tennessee Medical Association
Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Avadel.
Edmund S Sabanegh, Jr, MD Chairman, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation
Edmund S Sabanegh, Jr, MD is a member of the following medical societies: American Medical Association, American Society of Andrology, Society of Reproductive Surgeons, Society for the Study of Male Reproduction, American Society for Reproductive Medicine, American Urological Association, SWOG
Disclosure: Nothing to disclose.
John P Mulhall, MD Director, Sexual and Reproductive Medicine Program, Memorial Sloan-Kettering Cancer Center
John P Mulhall, MD is a member of the following medical societies: American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Society for Basic Urologic Research, Society of University Urologists
Disclosure: Nothing to disclose.
Jonathan D Schiff, MD Assistant Clinical Professor of Urology, Department of Urology, Mount Sinai Medical Center; Adjunct Assistant Clinical Professor of Urology, Weill-Cornell School of Medicine
Jonathan D Schiff, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.
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