Adam Walsh

Age: 28 years old male

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and diagnosis 

  • Signpost sensitively to the patient that you will be asking some personal and intimate questions to understand the issue properly
  • Ask how long the symptom has been present
  • Ask if the blood has been noticed once or on multiple occasions (A single episode of haematospermia in a young, otherwise healthy male is often benign and self-limiting. Recurrent or persistent haematospermia raises the index of suspicion for more serious causes)
  • Ask about the colour of the semen — is the blood bright red or brownish? Bright red blood (with or without clots) suggests fresh bleeding, whereas brown or rust-coloured blood usually indicates older bleeding that has had time to break down. 
  • Ask if there is pain during ejaculation (This can suggest prostatitis, urethritis, orchitis, epididymitis, seminal vesicle stones or other inflammatory conditions)
  • Ask about any urinary symptoms: pain passing urine, urgency, frequency, nocturia
     (This may mean an infection like urinary tract infection or prostatitis)
  • Ask if there is any blood in the urine (haematuria)- This could indicate a urinary tract malignancy, infection or bladder/kidney stones)
  • Ask about pain in the perineum, testicles, or lower abdomen- (Pain in these areas can be associated with prostatitis, epididymitis, or pelvic infections)
  • Take a sexual history: number of partners, use of condoms (protection), history of STIs, and if STI screening has been done (To rule out sexually transmitted infections such as chlamydia or gonorrhoea, which can cause haematospermia)
  • Ask about any trauma to the groin or pelvic area (Trauma can lead to local bleeding into the seminal tract)
  • Ask about bleeding from any other sites (e.g. gums, nose, rectum) to rule out bleeding disorders
  • Ask about over-the-counter or regular medications, particularly NSAIDs or blood thinners (NSAIDs like ibuprofen and anticoagulants can increase bleeding risk)
  • Ask about alcohol use, smoking habits, and recreational drug use
  • Ask about any high-risk physical activities (e.g. frequent cycling, horse riding)- (Such activities can cause repetitive trauma to the perineal area)
  • Screen for red flags: fever, chills, general malaise (infection), weight loss, night sweats (possible malignancy)
  • Ask about family history of prostate, testicular, or urinary tract cancers
  • Ask about anaemia red flags if bleeding is heavy: 3 head (headaches, dizziness, light-headedness) and 3 Chest (palpitations, chest pain, breathlessness) 
  • Make a working diagnosis of haematospermia (blood in semen)

Example of explanation to patient​

Adam, I can completely understand how worrying it must be to see blood in your semen. It’s not something anyone expects, and it’s good that you’ve come forward to talk about it. The medical term for this is haematospermia, which simply means blood in the semen, and while it can sound alarming, the reassuring news is that in most cases, it isn’t caused by anything serious.

There are a few possible explanations. One is that it could be linked to your use of ibuprofen for migraines, especially if you’ve been using it frequently. While it’s not a very common side effect, taking painkillers like ibuprofen in high amounts can sometimes affect how your blood clots — it slightly thins the blood by interfering with substances that help it clot properly. This might make small blood vessels, like those around the prostate or in the reproductive system, more prone to bleeding. So, this could be playing a part in what you’re noticing.

Another possible cause is infection, but since your STI tests and urine test were all clear, an infection is much less likely in your case. However, just to be thorough, I’d like to arrange a test on a semen sample to check for any hidden infections that might not show up in urine.

You mentioned that you’re worried this could be cancer, and I completely understand why you’re concerned. But from everything you’ve told me so far, this doesn’t sound like anything cancerous. Cancer in someone your age, without any other worrying symptoms, is uncommon. But to be thorough, I’d still like to examine you in person, just to check your abdomen, your prostate, and the genital area to make sure we’re not missing anything. Does that sound all okay to you? 

I’d also recommend we do some blood tests, including a full blood count to check for signs of infection or inflammation, and to see if you might be a bit anaemic from any ongoing blood loss, a test called clotting profile to test for how well your blood is clotting, kidney and liver function tests which are part of routine health checks. Although you’re under 40 and prostate cancer is very unlikely at your age, we might still do a PSA test — that’s a marker that gives us an idea of how your prostate is functioning. This is just to be thorough because of the bleeding you’ve had.

Most cases of blood in the semen do settle down on their own. But if it continues, worsens, or if you notice any other symptoms like pain, weight loss, or fever, let us know so we can explore further. In the meantime, I would suggest you discontinue ibuprofen, and we can talk about safer ways to manage your migraines. 

Management

  • Offer face-to-face review to check his blood pressure, examine his abdomen, genital area, and perform a prostate exam.
  • Offer to send semen sample for culture to rule out infection not picked up by initial tests. No need to repeat urine culture as it was already done and found normal
  • Offer blood tests including full blood count (FBC), clotting profile, urea and electrolytes (U+Es), liver function tests (LFTs)
  • Although PSA is generally offered to men over 40 with haemtospermia, discuss and offer it given the patient’s concern about cancer and for completeness.
  • Advise him to stop taking ibuprofen regularly as it can increase bleeding tendency; offer follow-up to review migraine management separately. Suggest using paracetamol in the meantime for headache relief.
  • If all tests return normal but haematospermia continues, refer to Urology for further specialist input
  • Reassure that in many cases, haematospermia resolves on its own and may not indicate anything serious
  • Reassure that haematospermia alone is unlikely to affect fertility unless other symptoms or conditions are present
  • Safety net: advise to return if symptoms persist, worsen, or new symptoms appear. 
  • Follow up with investigation results. 

Learning point from this station: ​

Haematospermia, or blood in the semen, though alarming for patients, is most often benign and self-limiting, particularly in men under 40 years of age with no other red flags. A careful, structured approach is important in assessing possible causes and deciding on appropriate next steps.

Key clinical considerations include:

  • Always signpost sensitively before asking intimate questions. A structured and thorough history helps rule out concerning causes such as malignancy or infection.
  • Assess for high-risk features such as recurrent or persistent bleeding, weight loss, systemic symptoms (fever, night sweats), testicular or perineal pain, and a history or family history of prostate or testicular cancer.
  • Investigations to offer include:
    • Urinalysis and mid-stream urine culture to rule out urinary tract infection, which can cause haematospermia.
    • Blood pressure measurement, as uncontrolled hypertension is a known cause of haematospermia.
    • Full blood count (to check for anaemia or infection), coagulation profile (to assess clotting), and renal/liver function tests (to evaluate baseline health and possible contraindications to medications).
    • PSA testing in all men aged over 40, and in younger men if symptoms or family history raise concern for prostate cancer.
    • Semen culture if there is suspicion of infection (e.g., TB, schistosomiasis).
    • Scrotal ultrasound if there is any testicular swelling or discomfort.
  • Medication history is essential — NSAIDs like ibuprofen can rarely cause thrombocytopenia or alter platelet function, potentially contributing to bleeding. This is listed as a rare side effect in the BNF.

Management guidance 

  • In men under 40, with no concerning features and normal investigations, reassure that haematospermia is likely benign and self-limiting.
  • If infection is suspected, refer to GUM clinic.

A referral to a urologist should be made in the following cases:

  • Any male patient of any age who presents with features that raise concern for prostate cancer — for example, a raised PSA or abnormal findings on digital rectal examination.
  • Men or boys who have symptoms that may suggest testicular cancer or any other urological malignancy.
  • These patients should be referred via the urgent suspected cancer pathway (to be seen within 2 weeks), in line with national guidelines.

Additionally, refer to urology in the following situations:

  • All men over the age of 40 where no clear cause for haematospermia has been identified in primary care. The referral should be urgent as haematospermia in men of this age could represent a malignancy 
  • Males of any age who: 
    • Continue to experience haematospermia despite appropriate treatment for an identified cause.
    • Have recurrent or persistent haematospermia with no identifiable cause found in primary care.
    • Have investigation results that suggest possible cysts or stones in the prostate or seminal vesicles.

Reassurance about fertility is important. Most causes of haematospermia do not impact fertility. STIs such as chlamydia or gonorrhoea are exceptions and must be treated accordingly.

Also, be mindful that haematospermia may occasionally be a presenting feature of a haematological malignancy, such as leukaemia or lymphoma. If other systemic symptoms or red flags are present, consider appropriate blood tests and haematology referral.