“There was blood when I ejaculated — I’ve convinced myself it’s cancer”

Haematospermia (blood in the ejaculate) is managed by AGE and red flags. In men UNDER 40 with a single or short episode and no red flags it is almost always BENIGN and self-limiting — commonly idiopathic, or due to inflammation/infection (prostatitis, urethritis, STI), recent instrumentation/prostate biopsy, vigorous sexual activity, or minor vessel bleeding — with cancer an uncommon cause, so strong, honest reassurance is appropriate after a sensible assessment. Take a targeted history (duration/recurrence, urinary symptoms, haematuria, STI risk/discharge, recent procedures, trauma, anticoagulants, fever, weight loss/bone pain), check BP (severe hypertension is associated), dip the urine/MSU, screen for STIs if indicated, and examine the external genitalia in person (a video consultation cannot do this), with DRE and PSA guided by age and findings (important in the older/persistent patient, more selective in a low-risk young man; PSA not within 48 hours of ejaculation or vigorous exercise, per the GOV.UK Prostate Cancer Risk Management Programme). Recognise the features that warrant INVESTIGATION/REFERRAL: age ≥40 (especially persistent or recurrent), associated visible/non-visible haematuria, an abnormal (hard/nodular) prostate, a raised age-adjusted PSA, or systemic red flags — these raise concern for PROSTATE cancer or other urological pathology, and NICE NG12 (Suspected cancer: recognition and referral, last updated April 2026) uses a suspected cancer pathway referral for a PSA above the age-specific range (40–49 above 2.5, 50–59 above 3.5, 60–69 above 4.5, 70–79 above 6.5 µg/L) or a malignant-feeling prostate, with separate routes for visible haematuria at 45+ (or non-visible at 60+ with dysuria or raised white cells) and for a testicular change. For the low-risk young man, treat any identified infection, give clear proportionate reassurance, and safety-net for persistence/recurrence, haematuria, urinary/systemic symptoms or reaching the age threshold. The communication core is the cancer FEAR fuelled by googling: acknowledge it, reassure honestly and proportionately (usually benign, rarely cancer in the young), and keep the threshold to investigate clear for the older/persistent/red-flag scenario — neither dismissive nor falsely alarming.