Blood in semen

Seeing blood in your semen is frightening, and the first thought is usually the worst one. So let us say it straight away: in men under forty this almost always comes to nothing and clears up on its own within days or weeks. But "almost always" is not "always" — there are ages and circumstances in which a single episode is already reason enough to be investigated. Below is how to tell the two apart, and what you will be asked at the appointment.

What it looks like, and what gets mistaken for it

Fresh blood is bright red. Brown, rusty or almost black blood has spent some time in the seminal tract and clotted; sometimes small clots are visible in it. The amount tells you almost nothing about the cause: a few drops are enough to colour the whole ejaculate, and it looks far worse than it is.

Before assuming the bleeding is yours, rule out the borrowed and the neighbouring:

• your partner's blood, either menstrual or from a small tear in the lining — this is the commonest false alarm;
• blood from the urethra after an injury or a catheter, which also shows up outside ejaculation and marks your underwear;
• a split or a graze on the skin of the penis, the foreskin or the frenulum.

If you are not sure, look again at the next ejaculation. A one-off episode in a young man that does not come back usually stays a one-off.

Why it usually happens

The commonest cause is inflammation of the prostate or of the seminal vesicles. There is a dense network of small vessels there, and inflammation makes them bleed easily. Close behind come inflammation of the urethra and of the epididymis, including the kinds caused by sexually transmitted infections.

The second large group of causes is mechanical:

• prostate biopsy. Most men have blood in their semen afterwards, and it can keep appearing for several weeks, sometimes longer. That is an expected consequence of the procedure, not a complication;
• other procedures: looking inside the bladder, prostate surgery, a vasectomy;
• a long spell of abstinence, when the contents of the seminal vesicles stagnate and the finest vessels give way;
• the opposite situation — very frequent or unusually vigorous sex;
• a blow to the perineum, or long hours on a bicycle or on horseback.

Often no cause is ever found. If you are under forty, the episode was a single one and nothing else is troubling you, that is the most likely outcome, and the investigation normally ends there.

When something more serious is behind it

Over forty, and at any age when episodes keep coming back, investigation is needed even if nothing hurts. In those situations the list of causes includes ones that will not resolve by themselves:

• a tumour of the prostate and, less often, of the bladder or the seminal vesicles;
• stones in the prostate or in the urinary tract;
• cysts and narrowings of the ejaculatory ducts;
• vascular abnormalities — dilated veins and small malformations that bleed with any straining;
• clotting disorders and blood-thinning medicines.

Blood pressure deserves a separate mention. Persistently high blood pressure can by itself cause this kind of bleeding, so it is always measured at the appointment. It is also the only way to find out that you have it: high blood pressure can go for years without giving any sign.

When to get help without waiting

Do not wait for a routine appointment — get help the same day if, along with the blood, there is:

• pain, a high temperature and shivering: this is what acute prostatitis looks like, and it is treated without delay;
• being unable to pass urine while the bladder is full — this is an emergency and cannot be left;
• blood in your urine at the same time as blood in your semen;
• severe pain, swelling or redness of the scrotum;
• a lump in a testicle — a firm nodule, usually painless.

Nor should you put off the appointment if the episodes are repeating, if you are over forty, if you take blood-thinning medicines, or if something else is bleeding too: your gums, your nose, or bruises appearing without any knock.

What happens at the appointment

It starts with the circumstances: how many times it has happened, what colour the blood was, whether there is pain, whether you have had any procedure recently, what medicines you take, whether you have a new sexual partner. After that, the usual steps are:

• examination of the external genitals and a rectal examination to assess the prostate;
• a blood pressure reading;
• a urine test with culture, and testing for sexually transmitted infections;
• blood tests and, where indicated, PSA, the protein whose level says something about the state of the prostate. It is read with your age in mind, and with the knowledge that a recent biopsy, inflammation or even cycling can push it up;
• an ultrasound scan and, if the episodes recur, an MRI scan of the pelvis or a look inside the bladder.

Does it need treating?

Most of the time there is nothing to treat: the blood goes on its own, and no remedy speeds that up to any noticeable degree. The point of seeing a doctor is not the treatment but ruling out the causes that do need acting on.

When a cause is identified, that cause is what gets treated. Bacterial inflammation and sexually transmitted infections are treated with antibiotics chosen for the organism, and the course is finished even if the blood disappeared on day two. With a sexually transmitted infection your partner needs testing and treatment as well. Stones, cysts, vascular findings and tumours are all handled differently, depending on what turns up. And if high blood pressure proves to be the cause, the blood pressure is what gets treated — that matters more than the episode itself.

Online consultation

In an online consultation the doctor goes through your case properly: how many episodes there have been, what colour the blood was, what happened in the days before, whether you have had any procedures and what medicines you take. They will tell you plainly whether you are in the group where watching and waiting is enough or whether you need investigation, and which part of this needs to be seen in person today. They will tell you which tests are worth having done before you see a urologist, so that you do not go twice, and read any results you already have, including PSA, which is easily misread. They will also go over the treatment you have been given and explain what your partner should do.

This material is for information only and does not replace medical advice.