Reasoning GP · Algorithm · 1-page summary
Haematospermia (blood in semen) in primary care
For: men presenting with blood in the semen. Not for: testicular pain, haematuria alone or a raised PSA alone (see those algorithms).
Core rule: a single episode in a man under 40 with a normal examination and urine is benign — but age over 40 with persistence or recurrence, haematuria, or an abnormal prostate or testis needs urine testing, PSA/DRE and the NG12 routes.
0Act now — before reassuring
- Fever >38°C, rigors, perineal pain, tachycardia or hypotension (acute bacterial prostatitis or epididymo-orchitis with sepsis) → Same-day / emergency assessment.
- Painful inability to pass urine (prostatitis, clot) → Same-day catheterisation and urology.
- Sudden severe testicular pain → possible torsion: 999 or A&E immediately.
1Triage — age, persistence, associated features
| Pattern | Route |
|---|---|
| <40, single episode | No red flags, haematuria or STI risk; normal examination and urine → reassure, safety-net |
| After a procedure | Expected for several weeks → reassure; review if it persists |
| STI risk, pain | STI screen, treat, notify partners |
| >40, persistent / recurrent | Urine, PSA/DRE after counselling; urology if unexplained or troublesome |
2Screen — NG12 routes (haematospermia alone is not one)
- Prostate feels malignant on DRE → Suspected cancer referral, whatever the PSA.
- PSA above age range (40–49 >2.5 · 50–59 >3.5 · 60–69 >4.5 · 70–79 >6.5 ng/mL) → Suspected cancer; under 40 or 80+: judgement.
- Aged 45+, unexplained visible haematuria, or persisting after treated UTI → Suspected cancer (bladder / renal).
- Painless testicular enlargement, or change in shape or texture → consider Suspected cancer; persistent testicular symptoms → consider direct-access ultrasound.
- Penile mass or ulcer, STI excluded or persisting after treatment → consider Suspected cancer.
- Weight loss, bone pain, night sweats → examine, PSA, relevant NG12 route.
3Assess
☐ Truly semen? (partner, urine) · episodes · procedures · anticoagulants, bleeding disorder, liver disease · family history, BRCA2, Black ethnicity · sexual history · freshwater travel ☐ BP, temperature, pulse, abdomen, testes ☐ Offer DRE (chaperone) with prostate symptoms, persistent episodes, abnormal PSA or visible haematuria ☐ All: dipstick + MSU ☐ PSA after counselling; not during UTI / prostatitis or within 6 weeks of treated UTI or biopsy; no ejaculation or vigorous exercise for 48 h ☐ STI risk: NAAT by exposure, HIV, syphilis ☐ Bleeding elsewhere: FBC, clotting, INR, LFTs
Not in primary care: transrectal ultrasound, MRI, semen culture. Tender boggy prostate: no prostatic massage.
4Classify — only if blocks 0–2 are negative
- Idiopathic — commonest in younger men → reassure; usually resolves.
- Iatrogenic — biopsy, vasectomy, catheter, cystoscopy, radiotherapy → reassure.
- Infective — prostatitis, epididymo-orchitis, urethritis (chlamydia, gonorrhoea, M. genitalium), UTI → treat the cause.
- Vascular / systemic — high BP, anticoagulation, bleeding disorder, liver disease → control BP; review medicines, clotting.
- Structural — seminal vesicle or ejaculatory duct cysts, calculi, enlarged prostate → urology imaging. Schistosomiasis after travel → terminal urine ova, serology, eosinophils; infectious diseases advice.
- Uncertain — say so; review, and refer if it persists.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Reassure; no medicine. If infection possible: condoms or no sex until STI assessment complete.
- Acute prostatitis: MSU if no delay; antibiotic per NG110 and local guidance, review at 14 days; fluoroquinolones only if others inappropriate (MHRA). Unwell, retention, immunocompromised, no oral intake or not improving → Same-day referral.
- Chlamydia: doxycycline 100 mg twice daily for 7 days; partner notification; abstain until treatment complete; test for gonorrhoea, syphilis, HIV.
- BP to NG136 target (under 80: clinic <140/90). Anticoagulants: do not stop automatically — review indication and risk.
6Refer routinely
- Persistent or recurrent (especially over 40), unexplained or troublesome after urine, PSA/DRE; persisting despite treatment of a cause; suspected cyst or calculus → local urology pathway.
- STI confirmed or suspected → sexual health; Urgent GUM for suspected gonorrhoea or M. genitalium.
- Coagulopathy or INR out of range → haematology / anticoagulation service.
- Schistosomiasis positive or strongly suspected → tropical medicine; do not treat automatically.
7Never reassure by
- Colour or amount — dark blood does not localise the source or exclude cancer or infection.
- A normal PSA when the prostate feels malignant.
- Haematospermia not being an NG12 criterion — persistence over 40 still needs review.
- Blaming visible haematuria on anticoagulation without investigation.
- Transillumination or absence of pain in a testicular mass.
- A PSA taken during infection — repeat it once the infection has settled.
8Safety-net — say it, then document it
999 “If you can't pass urine at all, have a fever with shivering and feel very unwell, or get sudden severe pain in a testicle, call 999 or go to A&E — don't drive yourself.” Same-day “Blood in your urine or a fever: contact us the same day.” Review after treatment: resolved? repeat MSU if haematuria; repeat PSA if taken during infection; persisting or recurring, weight loss or bone pain → reassess and urology.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies; testes examined
DRE offered when indicated; urine dipstick + MSU done
PSA decision documented with age range
STI risk assessed; partner notification if needed
Safety-net and review documented
Summary of the full Reasoning GP haematospermia algorithm, which holds the history, causes, investigation detail and evidence. Sources: NICE NG12 (updated April 2026), NICE NG110 acute prostatitis, MHRA fluoroquinolone update (January 2024), BASHH chlamydia guideline (2026) and STI testing guidance (2023), NICE NG136, GOV.UK PSA testing guidance, EAU Sexual and Reproductive Health (haemospermia). Clinical reference — follow local pathways.