The most common causes of hematospermia are inflammation and infection of the seminal vesicles and prostate. Other rare causes include ejaculatory duct obstruction or cysts, stones and tumors of the seminal vesicles and prostate, vascular malformations, tuberculosis of the seminal vesicles, diverticula of the seminal vesicles, injury to the seminal tract and medical factors such as transrectal prostate puncture biopsy. In addition, benign prostatic hyperplasia, varicocele, testicular tumors and some systemic diseases such as bleeding disorders, liver function abnormalities and severe hypertension can also cause hematospermia. Fleming et al. reported a case of hematospermia in a patient with malignant hypertension, and the hematospermia disappeared after blood pressure control. Pathogenic microbial infections can be detected in about 75% of hematospermia, but in patients with recalcitrant hematospermia, it is often clinically difficult to detect pathogenic microorganisms because antibiotics have been repeatedly applied several times. The seminal vesicles both store sperm and secrete seminal fluid. The seminal vesicles are rich in tiny vascular layers and contain many microvessels, so they are easily damaged and bleed. Hemosperm almost always occurs during orgasm, and when ejaculation occurs, smooth muscles contract fiercely and small blood vessels rupture and hemosperm can occur. The hematosperm is related to excessive congestion, friction and extrusion of the seminal vesicles. The inflammatory reaction of the seminal vesicles can make the mucous membrane of the seminal vesicles congested and edematous, resulting in hematosperm during ejaculation. Hemosperm can develop in men of all ages after sexual maturity, and the course of the disease is often intermittent, and sometimes it can heal itself. For patients with hematospermia, urine and transrectal prostatic seminal vesicle ultrasound should be routinely performed, as well as routine prostate and semen examinations and bacterial culture and drug sensitivity tests if necessary. Transrectal ultrasound should be used as the imaging test of choice for hematospermia, and there are reports in the literature that transrectal ultrasound found 83% of abnormal lesions in the diagnosis of hematospermia. For patients over 40 years of age, especially those with a family history of prostate cancer, blood should be drawn for PSA prior to prostate finger examination and combined with rectal examinations, TRUS, and MRI to rule out the possibility of prostate tumors causing hematospermia. Since routine laboratory tests and TRUS may still be difficult to clarify the site and cause of bleeding. If the cause is still not clear after the above examinations, further imaging examinations such as MRI of the prostate and seminal vesicles or multi-row CT can be performed to help clarify the cause of hematemesis in order to exclude prostate and seminal vesicle tumors. MRI can sometimes also show the secondary gonads and their ducts, and whether there is a combination of other anatomical abnormalities or lesions. Most patients with hematospermia can heal spontaneously within a few weeks or after treatment with sensitive antibiotic drugs. The occurrence of hematospermia can be effectively prevented by a light diet, less spicy and stimulating food, less smoking and alcohol, avoiding sedentary and holding urine, and a moderate and regular sex life. However, there are still a few patients with recurrent hematospermia, and the conventional treatment methods are ineffective and become recalcitrant hematospermia, which is more difficult to treat at this time. The latter includes prostate massage, hot water bath, physiotherapy, etc. to improve local tissue blood circulation and promote the absorption and discharge of inflammatory substances. Because of the special anatomical and physiological characteristics of the seminal vesicles and prostate, the above methods are often ineffective or ineffective in treating intractable hematospermia. For patients with recalcitrant hematospermia, in addition to detailed questions about the frequency of episodes, precipitating factors and the medications and other treatments applied, we should also ask whether they have used anticoagulant drugs such as aspirin, and whether they have abnormal liver function or malignant hypertension, in order to understand the causes of hematospermia. In China, there are reports in the literature on the efficacy of transrectal ultrasound-guided perineal seminal vesicle aspiration (SVF) for pathogenic and cytologic examination, simultaneous indwelling seminal vesicle catheterization and continuous drip of sensitive antibiotics in the treatment of recalcitrant hematospermia. However, the method is complicated, and the patient has obvious pain and discomfort after perineal seminal vesicle placement, and is prone to infection, so its clinical application is limited. In contrast, transurethral vesiculoscopy is performed under sacral or lumbar anesthesia, which significantly reduces the patient’s pain. Under direct vision, not only can the cause and location of hematospermia be clearly identified, but also the need to leave a catheter in place for postoperative contrast or drug infusion can be decided according to the intraoperative microscopic examination. We have used seminal vesicle microscopy to treat patients with recalcitrant hematospermia with remarkable efficacy, and have conducted a long follow-up after surgery with a long-term efficiency of 90%. Transurethral vesiculoscopy is simple and minimally invasive, and can be one of the effective methods for the diagnosis and treatment of recalcitrant hematospermia.