Analysis of the causes of hematospermia and guidelines for the emergency treatment of priapism.

Hematospermia (Blood in Semen)

Normal male semen is milky white or milky yellow. If, for some reason, the ejaculated semen turns pink, red, brownish-red, or contains blood streaks, it is called hematospermia, also known as blood in semen. If the ejaculated semen is visible to the naked eye as pink or red, it is called "gross hematospermia," which is a severe case. Mild hematospermia is not visible to the naked eye. Microscopic examination of the semen reveals red blood cells, which is called "microscopic hematospermia."

Hematospermia is one of the more common reproductive system infections in men. The most common cause of hematospermia is seminal vesiculitis. The seminal vesicle has a rich layer of tiny blood vessels containing numerous capillaries, which are easily damaged and bleed. Simultaneously, because the seminal vesicles are located adjacent to organs such as the prostate, urinary tract, and rectum, bacteria can easily spread to the seminal vesicles if inflammation occurs in these areas, causing inflammation, swelling, congestion, and bleeding, resulting in hematospermia. It is often accompanied by perineal, rectal, and lower abdominal pain or dysuria. Seminal vesiculitis includes both acute and chronic forms. In acute seminal vesiculitis, bacteria mainly invade through the posterior urethra, entering the seminal vesicles via the prostatic ducts. In addition, excessive alcohol consumption, exposure to cold, or excessive sexual activity can all induce seminal vesiculitis. Acute inflammation of the seminal vesicles causes congestion and edema; if the lesion is severe or incompletely treated, it can further develop into chronic seminal vesiculitis. Furthermore, frequent sexual arousal or excessive masturbation can cause congestion of the seminal vesicles and prostate, followed by secondary infection, leading to chronic seminal vesiculitis.

The condition of hematospermia is well-documented in traditional Chinese medicine literature throughout history. For example, the *Treatise on the Causes and Symptoms of Various Diseases* states, "This is due to overwork damaging the kidney qi. The kidney stores essence, which is formed from blood. When the kidney is deficient, it cannot store essence, hence the loss of both essence and blood." This suggests that the disease is caused by a deficiency of essence and blood.

The main symptom of hematospermia is the discharge of blood during sexual intercourse, which may be accompanied by mild perineal and lower abdominal distension and pain. Chronic seminal vesiculitis commonly occurs between the ages of 25 and 40, and hematospermia is a characteristic feature of chronic seminal vesiculitis. The semen is bright red or dark red, with reduced semen volume, decreased sperm count, or increased dead sperm. Microscopic examination of the semen reveals a large number of red blood cells and pus cells. Hematospermia can sometimes cause sexual dysfunction.

Prevention and Treatment: When hematospermia occurs, do not panic or feel burdened. Seek timely treatment. If hematospermia is not caused by a tumor, treatment is generally effective. If hematospermia occurs occasionally and no pathological examination is found, it is mostly caused by the sudden congestion of the reproductive organs and the rupture of capillaries during sexual intercourse. This is called transient hematospermia, and it will heal on its own after abstaining from sexual activity for several days without any treatment. Avoiding excessive sexual activity and preventing urinary tract infections are important measures to prevent this condition. Sometimes hematospermia can resolve on its own; avoiding overexertion and maintaining hygiene during sexual intercourse are also very important.

Drug Treatment

If hematospermia persists, a medical examination and treatment are necessary. Hematospermia is mostly caused by seminal vesiculitis, prostatitis, or posterior urethritis, and antibiotics should be used to treat the underlying cause. Penicillin 800,000 units can be administered intramuscularly twice daily, or streptomycin 0.5 g twice daily, or gentamicin 80,000 units intramuscularly twice daily. Other antibiotics such as tetracycline and sulfonamides can also be used. Symptomatic treatment can also be used, such as hemostatic drugs like Vitamin K₃ and tranexamic acid.

Comprehensive Treatment: Seminal vesicle and prostate massage can help drain the fluid containing cells from the seminal vesicles, facilitating recovery. Physiotherapy and hot baths can accelerate the resolution of inflammation. A small number of cases of hematospermia are caused by seminal vesicle tuberculosis or prostate tuberculosis; a very small number are caused by seminal vesicle tumors or posterior urethral tumors, requiring specialist diagnosis and treatment.

Priapism

Priapism refers to a sudden, persistent erection of the penis without sexual desire or stimulation, characterized by thickening and hardening of the penis, accompanied by pain at the base of the penis but no pain in the glans. The erection can last for hours, days, or weeks. Sometimes ejaculation occurs, but the erection continues after ejaculation. If left untreated, it can cause fibrosis of the corpora cavernosa, leading to permanent impotence, and can also cause necrosis of penile components. Traditional Chinese medicine (TCM) calls this condition "Yang Qiang" or "Qiang Zhong," and it has been recorded in ancient books. The *Zhu Bing Yuan Hou Lun* describes its symptoms: "Those with Qiang Zhong experience prolonged and unabated erection, and spontaneous ejaculation." TCM believes that various factors leading to heat toxins and blood stasis obstructing the genitals can trigger this condition. For example, discomfort in the abdomen and stagnation of liver qi can lead to heat accumulation over time; rich and fatty foods, such as ginseng and deer antler, can generate heat and toxins; excessive sexual activity can damage liver and kidney yin, leading to hyperactivity of the ministerial fire; injuries from falls and blows can also cause heat accumulation over time.

The causes of priapism can be divided into primary and secondary types. The cause of primary priapism remains unclear; secondary priapism has four causes:

① Neurological: caused by lesions of the spinal nerves or nerves distributed around the genitals, such as spinal cord injury or neurotoxins.

② Mechanical causes: Late-stage pelvic tumors, infiltration and compression, continuous pressure on the penile root from external forces (such as metal rings), local penile trauma, etc.

③ Hematological diseases: Leukemia, polycythemia vera, sickle cell anemia, thrombophlebitis, glucose-phosphodiesterase deficiency, etc.

④ Drug-related causes: Use of thiazides, testosterone, hydralazine, and so-called "aphrodisiacs," etc.

Generally, priapism is considered a functional disorder in the penis's return to a non-congested state. Venous return is obstructed, blood pools, leading to increased carbon dioxide tension, decreased oxygen content, and a dramatic increase in blood viscosity, causing obstruction at the corpora cavernosa and the junctions of converging veins. Penile edema further exacerbates venous return obstruction, eventually leading to thrombosis and arteriolar occlusion. Fibrosis of the corpora cavernosa will ultimately result in loss of erectile function.

Treatment methods

Priapism should be treated promptly. Priapism is characterized by significant swelling, pain, and tenderness of the corpora cavernosa, constituting an emergency requiring prompt treatment to restore venous return and prevent or minimize damage to the erectile tissues. The goal of treatment is to achieve early deflating of the erect penis, reduce swelling, and restore normal sexual function.

Specific treatment methods can be divided into two categories:

1. Non-surgical treatment

Non-surgical treatment includes local cold compresses, sedation and antispasmodics, local nerve blocks, sacral anesthesia, spinal anesthesia, acupuncture, aspiration, and the use of anticoagulants, estrogen, fibrinolytic agents, and antihypertensive drugs. Some non-surgical treatments may not be able to achieve complete deflating of the erect penis. Some believe that most patients do not regain normal sexual function after non-surgical treatment and therefore do not advocate its use.

2. Surgical treatment

The purpose of surgical treatment is to reduce arterial blood flow to the penis and increase venous blood outflow, thereby promoting rapid deflating of the erect penis. Some have suggested ligating the pudendal artery to reduce blood flow to the penis, thus causing flaccidity. However, others believe that ligation of the pudendal artery can lead to erectile dysfunction. A more reasonable treatment method is a shunt procedure that increases venous blood outflow from the penis, including:

① External bypass shunt.

② Great saphenous vein-corpus cavernosum anastomosis.

③ Dorsal vein-corpus cavernosum anastomosis.

④ Corpus spongiosum-corpus cavernosum anastomosis.

⑤ Penile glans-corpus cavernosum shunt, etc.