Hemospermia is a common male and urological condition that refers to the presence of blood in the semen. Depending on the amount of blood contained, it can manifest as naked eye hematosperm, semen mixed with blood or a small amount of red blood cells under the microscope. Strictly speaking, hematospermia is only a clinical manifestation and not a disease. Hemospermia can occur at any age after development, and is generally common in young adults aged 30 to 40 years old who are in the prime of sexual activity, with 80% to 90% having intermittent episodes. Hemospermia is mostly a benign self-limiting disease that requires only conservative treatment. However, some patients with severe intractable hematospermia may be at risk for other potentially serious pathological changes and further therapeutic measures should be used. Etiology Hemospermia can be caused by various sites and tissue lesions in the semen transport pathway, but mainly originates from the seminal vesicles, prostate and posterior urethra. Hemospermia can be classified as functional and organic. Functional hematosperm is caused by the contraction of the male during orgasm and the change in relaxation after ejaculation is completed, resulting in a rapid change in pressure in the seminal vesicle gland and damage to the capillaries on the vesicle wall causing bleeding or capillary permeability change and blood leakage. Organic hematospermia is caused by certain diseases, common causes include: 1. Inflammation Reproductive system infection is the most common cause of hematospermia. Infection causative agents include viruses, bacteria, Mycobacterium tuberculosis and parasitic infections, etc. It can also be the result of trauma, urethral foreign bodies, and chemicals. The common causes are seminal vesiculitis, prostatitis, posterior urethritis, seminal vesicle tuberculosis, and epididymal orchitis. Stones in the prostate, seminal vesicles or vas deferens can also cause hematospermia. 2, obstruction or cysts Ejaculatory duct obstruction can cause expansion and swelling of the proximal ducts of the obstruction, resulting in rupture of mucosal vessels and bleeding, commonly including seminal cysts, ejaculatory duct cysts, seminal diverticula, nocturnal non-duct cysts and prostatic cysts. 3, tumors A variety of benign tumors of the genitourinary tract can cause hematospermia, such as posterior urethral adenoma, smooth muscle tumor, fibroma, adenoma-like polyps and prostatic hyperplasia. Malignant tumors of the bladder, prostate, testes and seminal vesicles can also cause hematospermia. 4, vascular abnormalities Varicose veins in the seminal vesicles, prostate urethra and bladder neck are the cause of hematospermia. In addition, vascular abnormalities of the reproductive system can cause hematospermia, including pelvic arteriovenous malformation, prostatic hemangioma, seminal vesicle and seminal cord hemangioma, etc. 5. Injuries Mostly medically induced, they are commonly seen in prostate puncture biopsy, intraprostatic drug injection, prostate cancer radiotherapy, transurethral instrumentation or pelvic surgery causing injury to the seminal vesicles, as well as after vasectomy, after extracorporeal shock wave lithotripsy of distal ureteral stones, and after injection therapy for hemorrhoids. In addition, it is also seen in perineal trauma, gonadal trauma, pelvic fracture, etc. 6, systemic factors Hypertension, hematological diseases (lymphoma, thrombocytopenia, leukemia, hemophilia) and anticoagulation abnormalities secondary to liver diseases can cause hematospermia. Clinical manifestations Hemospermia is characterized by blood in the semen during ejaculation as the main symptom, and may be accompanied by painful ejaculation, decreased libido, premature ejaculation, perineal pain and discomfort, initial or final hematuria after seminal discharge, and bladder irritation symptoms. The characteristics of functional hematemesis are: in the absence of seminal discharge for a longer period of time, once seminal discharge is easy to appear hematemesis, not accompanied by other symptoms, short duration and easy recurrence. The appearance of hematosperm differs due to different causes, sites, amounts and length of bleeding: hematosperm caused by inflammation and injury is mixed evenly; when it comes from the urethral mucosa bleeding, it is manifested as semen mixed with bright red blood, not mixed with semen; if the bleeding stores the seminal vesicles for a long time, it is often coffee-colored; if it is fresh bleeding, it is pink. The vast majority of patients with hematospermia have a small amount of bleeding, which can be initial, terminal or full hematospermia. Examination 1, laboratory tests including urinalysis, urine bacterial culture and drug sensitivity test and detection of Chlamydia spp. Routine semen or prostate fluid examination shows a significant increase in red blood cell and white blood cell counts. If necessary, semen bacterial culture plus drug sensitivity test is feasible, and the diagnosis of tuberculosis can be clarified by using PCR technology. Those over 40 years of age should also have their sera checked for prostate-specific antigen (PSA). In addition, routine blood, liver function, kidney function, coagulation time and electrolyte examination should be done to exclude chronic diseases and hematospermia caused by bleeding qualities. (1) Transrectal ultrasonography is the preferred method to examine hematospermia, and can be performed simultaneously with seminal vesicle aspiration and biopsy or prostate aspiration biopsy to further clarify the cause of hemorrhage. （MRI is considered to be the “gold standard” for imaging the gonads, accessory gonads and ducts of the body. (3) Endoscopy When there is a suspicion of hemorrhage caused by lesions in the urethra, bladder, ejaculatory duct or seminal vesicles, cystourethroscopy, ureteroscopy or seminal vesiculoscopy can be performed. Previously commonly used abdominal plain film, excretory urography, vasovasography or seminal vesiculography may provide limited information, but are rarely used for the diagnosis of hematospermia at present. CT is not superior to transrectal ultrasound and MRI. Diagnosis The diagnosis of hematospermia is based on history, general examination, and urinary and genital tract examinations. Care is taken to exclude the possibility of bleeding in the sexual partner at the time of diagnosis. It is important to differentiate it from the extremely rare black sperm. The latter is a malignant melanoma occurring in the prostate, seminal vesicles or genitourinary tract and is characterized by dark brown semen or dark brown spots in the semen. Treatment For functional hematospermia, idiopathic hematospermia and hematospermia of medical origin, symptomatic treatment such as stopping bleeding, suspending sexual intercourse and preventing infection is the main treatment, and some patients can often heal on their own. If it is due to infection, drug and symptomatic treatment is feasible. Combined antibiotic and finasteride treatment is an effective method to treat infective hematospermia. In a small number of patients with tuberculosis, surgical treatment is feasible if necessary. Intractable recurrent hematospermia can be treated with transurethral ureteroscopic or vesiculoscopic seminal vesicle irrigation, ultrasound-guided perineal or transabdominal seminal vesicle puncture and irrigation, depending on the situation. Posterior urethral polyps, adenomas, vascular lesions and other urethral diseases causing hematospermia can be cured by transurethral electrodesiccation or electrocautery, while patients with bladder cancer, prostate cancer and seminal vesicle cancer require surgical treatment. Prognosis Clinically, most cases of hematospermia are mild and can be cured spontaneously. If the lesion is benign, the prognosis is better, but recurrence is still possible. In case of malignant lesions, the prognosis is related to the clinical and pathological stage of the primary disease. Prevention Moderate sexual life, not too frequent and intense, and not too long abstinence. Avoid drinking alcohol and spicy stimulating food, and do not ride a bike for long distances to avoid recurrence of the disease. Those who have already had children can take a warm water bath at 41°C to 42°C once a day for 15 to 20 minutes. For those who have not yet had children, avoid taking sitz baths to avoid high temperatures affecting sperm quality.