QuestionI have blood in my semen but not in my urine. What could be the cause?
AnswerThis is called hematospermia and can be serious enough to see your doctor for tests. Most of the time it is prostate in origin and is treated with antibiotics but cancer has to be checked out just to be sure. OK?
more information..
One of several inflammatory and/or painful conditions affecting the prostate gland
Acute bacterial prostatitis - generally associated with urinary tract infection, has characteristically abrupt onset
Chronic bacterial prostatitis - major cause of recurrent bacteriuria, less fulminant
Chronic prostatitis/pelvic pain syndrome
Inflammatory - inflammatory cells in prostatic secretions, post prostate massage urine or seminal fluid
Noninflammatory - similar to chronic bacterial, but bacterial culture negative
Asymptomatic inflammatory prostatitis - incidental finding during prostate biopsy of infertility, cancer workup
System(s) affected: Reproductive, Renal/Urologic
Genetics: No known genetic pattern
Incidence/Prevalence in USA: Common
Predominant age:
Mostly ages 30-50, sexually active
Chronic more common in ages over 50
Predominant sex: Male only
SIGNS AND SYMPTOMS
Acute bacterial
Fever; chills
Tense, boggy, very tender and warm prostate
Low back pain
Perineal pain
Frequency
Urgency
Dysuria
Nocturia
Bladder outlet obstruction
Chronic bacterial
Symptoms often absent
Perineal pain
Dysuria
Irritative voiding
Lower abdominal pain
Low back pain
Scrotal pain
Penile pain
Pain on ejaculation
Hematospermia
Chronic prostatitis/pelvic pain syndrome
Similar to chronic prostatitis
CAUSES
Acute and chronic bacterial
Ascending infection through urethra
Refluxing urine into prostate ducts
Direct extension or lymphatic spread from rectum
Hematogenous spread
Calculi serving as nidus for infection
Aerobic gram negative bacteria (Escherichia coli, Pseudomonas, Klebsiella, Proteus), N. gonorrhea, Enterobacteriaceae
Miscellaneous - Chlamydia trachomatis
Gram positive bacteria (Streptococcus faecalis, Staphylococcus. aureus)
Organisms suspected, but unproven (Staphylococcus epidermidis, Micrococci, non-group D streptococcus, Diphtheroids)
Nonbacterial
Non-relaxation (spasm) of the internal urinary sphincter and pelvic floor striated muscles leading to increased prostatic urethral pressure and intraprostatic urinary reflux leading theory
Ureaplasma, trichomonas vaginalis, and Chlamydia postulated, but not proven
RISK FACTORS
Male sex
Age over 50
Prostatic calculi
Urinary tract infection
Trauma
Dehydration
Sexual abstinence
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Cystitis (bacterial, interstitial)
Urethritis
Pyelonephritis
Malignancy
Obstructive calculus
Foreign body
Acute urinary retention
LABORATORY
4 Glass test
Fractional urine examination (initial 10 mL from urethra for voided bladder 1 (VB1) test, next 200 mL discarded, then midstream from bladder for VB2 test, then expressed prostate secretion (EPS), lastly urine after prostate massage for VB3 test. Some feel vigorous massage may lead to bacteremia.
Urinalysis, culture, sensitivities on all samples
Over 10-15 white cells per high powered field or positive culture in EPS or VB3 but not VB1 or VB2 diagnostic of bacterial prostatitis
Bacteria count generally less in chronic than acute
Macrophages containing fat (oval bodies) in bacterial prostatitis
Antigen-specific IgA and IgG levels in prostatic fluid helpful for diagnostic confirmation and determining response to therapy
Alkaline pH of prostatic fluid in chronic bacterial prostatitis
Nonbacterial will show white blood cells with a negative culture
No abnormal findings with chronic prostatitis without inflammation
Drugs that may alter lab results: Antibiotics
Disorders that may alter lab results: N/A
PATHOLOGICAL FINDINGS
Inflammatory changes (except prostatodynia)
SPECIAL TESTS
N/A
IMAGING
CT or ultrasound, if malignancy or abscess suspected
Transrectal ultrasound (if prostatic calculi or abscess suspected)
DIAGNOSTIC PROCEDURES
Needle biopsy or aspiration for culture
Urodynamic testing (prostatodynia)
Cystoscopy (in persistent nonbacterial prostatitis to rule out bladder cancer, interstitial cystitis)
TREATMENT
APPROPRIATE HEALTH CARE
Inpatient (proven or suspected abscess, urosepsis, immunocompromised)
Outpatient, if nontoxic
GENERAL MEASURES
Analgesics
Antipyretics
Stool softeners
Hydration
Sitz baths to relieve pain and spasm
Suprapubic catheter for severe urinary retention
Psychotherapy if sexual dysfunction
SURGICAL MEASURES
Surgical resection for intractable chronic disease, or to drain an abscess; transurethral microwave thermotherapy for chronic nonbacterial prostatitis
ACTIVITY
Bedrest in severe cases
DIET
Nonbacterial and prostatodynia - avoid spicy foods, excess caffeine and alcohol
Acute and chronic bacterial - no special diet
PATIENT EDUCATION
Printed patient information available from: National Kidney & Urologic Diseases Information Clearinghouse, Box NKUDIC, Bethesda, MD 20893, (301)468-6345
MEDICATIONS
DRUG(S) OF CHOICE
Acute bacterial (outpatient): Trimethoprim-sulfamethoxazole (Septra), double strength, two tablets, twice daily for 30 days
Acute bacterial (inpatient): Ampicillin 1-3 gram IV divided q6h plus aminoglycoside - gentamicin 2.0 mg/kg loading dose; 1.7 mg/kg q8h maintenance
Chronic bacterial: A fluoroquinolone (ofloxacin 300 mg bid, ciprofloxacin 500 mg bid) at standard dose for 4-12 weeks
Nonbacterial: May benefit from erythromycin, doxycycline, trimethoprim-sulfamethoxazole
Chronic prostatitis/pelvic pain syndrome without inflammation - alpha-adrenergic blocking agents may be useful
Analgesics
Antipyretics
Stool softeners
Contraindications: Drug allergies
Precautions:
Renal disease
Hepatic disease
Elderly
G6PD deficiency
Significant possible interactions: Fluoroquinolones with magnesium/aluminum antacids, theophylline, probenecid, NSAIDs, warfarin
ALTERNATIVE DRUGS
Carbenicillin with aminoglycoside, erythromycin, tetracycline, cephalexin, fluoroquinolones
FOLLOWUP
PATIENT MONITORING
Acute bacterial - urinalysis and culture 30 days after initiating treatment
Chronic bacterial - urinalysis and culture every 30 days (may take several months)
PREVENTION/AVOIDANCE
Suppression therapy may benefit patient with chronic bacterial prostatitis
POSSIBLE COMPLICATIONS
Abscess
Sepsis
Urinary retention
EXPECTED COURSE/PROGNOSIS
Often prolonged and difficult to cure. Studies with 55-97% cure rate depending on population and drug used.
MISCELLANEOUS
ASSOCIATED CONDITIONS
Prostatic hypertrophy
Cystitis
Urethritis
AGE-RELATED FACTORS
Pediatric: None
Geriatric: Consider prostatic hypertrophy and urinary retention more seriously
Others: N/A
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Obstructive symptoms are distinct from irritative symptoms such as frequency, dysuria, or urgency, which may occur from infectious, inflammatory, or neoplastic diseases. Conditions that can mimic cancer include acute prostatitis, granulomatous prostatitis, and prostate calculus. Prostatitis usually produces induration and/or pain and is treated with antibiotics. Prostate cancer may manifest in the same manner, and the distinction can only be established histologically, but a biopsy should not be performed before a trial of antibiotics if prostatitis is a possible diagnosis. In cases where the tumor has extended beyond the confines of the gland, symptoms of hematospermia or erectile dysfunction may occur. Prostate cancer may also present with pain secondary to bone metastases, although many patients are asymptomatic despite extensive spread. Less common presentations include myelophthisic disorders, disseminated intravascular coagulation, or spinal cord compression. The proportion of men diagnosed at these late stages has also decreased significantly as a result of PSA-based detection strategies.
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