Hematospermia, the presence of blood in the semen,

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1 Journal of Andrology, Vol. 33, No. 5, September/October 2012 Copyright E American Society of Andrology The Value of Transrectal Ultrasound in the Diagnosis of Hematospermia in a Large Cohort of Patients HONGWEI ZHAO, JUNHANG LUO, DAOHU WANG, JIAN LU, WANMEI ZHONG, JINHUAN WEI, AND WEI CHEN From the Department of Urology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China. ABSTRACT: Several studies have proved transrectal ultrasonography (TRUS) is efficient in the evaluation of patients with hematospermia, but the numbers of patients were less than 60 in each of the previous reports. Herein, a total of 270 patients with hematospermia were evaluated by TRUS to assess its efficacy in the etiologic diagnosis of hematospermia. The age of patients ranged from 15 to 75 years (x, 41.2 years), and the duration of symptoms was 1 day to 8 years (x, 3.4 months). Abnormalities were revealed by TRUS in 256 patients (94.8%). The percentages of pathological conditions located in the seminal vesicles, in the ejaculatory ducts, in the prostate, and in the bladder were 46.3% (125 cases), 29.6% (80 cases), 55.2% (149 cases), and 0.4% (1 case), respectively. The number of patients older than 40 years old and 40 years old or younger were 126 and 144, respectively. Our results show significantly higher percentages for malignant diseases, prostatic calcification and benign prostatic hyperplasia in the group of patients more than 40 years old compared with the group of patients 40 years old or less. Eight of 270 patients (3.0%) had malignant tumors, and all of the 8 malignancies occurred in patients more than 40 years old. TRUS is a noninvasive, reliable tool for the investigation of causes of hematospermia. Hematospermia is generally a benign symptom in younger patients. Special attention should be paid to elderly patients to exclude malignancy. Key words: Transrectal ultrasonography, TRUS. J Androl 2012;33: Hematospermia, the presence of blood in the semen, is a symptom not uncommonly encountered in clinical practice. Hematospermia can be caused by various pathologies, from infectious to malignant processes (Worischeck and Parra, 1994). Hematospermia is a disconcerting symptom that produces extreme anxiety in sexually active male patients (Munkel et al, 1997). Patients with hematospermia are often fearful of cancer and making love. Usually we are not able to offer a complete and satisfactory explanation because history and physical examination are often unrevealing. Its clinical significance and causes were largely speculative before the advent of modern imaging techniques, and the most common form of hematospermia was considered essential hematospermia. However, patients presenting hematospermia might not be satisfied with our empirically derived reassurance that it could be an idiopathic and usually self-resolving condition of little Supported by the National Natural Science Foundation of China ( ) and Guangdong Provincial Science and Technology Foundation (2008B , 2010B ). Correspondence to: Dr Junhang Luo and Dr Wei Chen, Department of Urology, the First Affiliated Hospital, Sun Yat-Sen University, No. 58, ZhongShan 2nd Rd, Guangzhou , China ( luojunh@mail.sysu.edu.cn and chenw3@mail.sysu.edu.cn). Received for publication February 6, 2011; accepted for publication April 20, DOI: /jandrol consequence. A definitive diagnosis of a specific pathological condition removes the anxiety and puts both the patient and the clinician at ease (Etherington et al, 1990). With modern imaging techniques, especially transrectal ultrasonography (TRUS), the number of cases labeled idiopathic has decreased dramatically (Ahmad and Krishna, 2007). TRUS transducers can provide both axial and sagittal images and thus improve the evaluation of hematospermia. Several reports have demonstrated that TRUS is a useful tool in the diagnostic workup of hematospermia, but the number of patients studied were less than 60 in each of the previous reports (Etherington et al, 1990; Amano et al, 1994; Worischeck and Parra, 1994; Yagci et al, 2004). Herein, a total of 270 patients with hematospermia were evaluated by TRUS to assess its efficacy in the etiologic diagnosis of hematospermia. Materials and Methods Patients A total of 270 consecutive male subjects presenting with hematospermia underwent transrectal ultrasound examination between January 2003 and September The duration of symptoms was 1 day to 8 years (x, 3.4 months). Hematospermia was defined as the presence of blood in the ejaculate (macroscopic or evaluated in the sperm analysis). The physical examination included the patient s temperature, blood 897

2 898 Journal of Andrology N September ÙOctober 2012 Figure 1. Transrectal ultrasonography (TRUS) characteristics of seminal vesicle abnormalities. (A) Seminal vesicle dilatation. Axial scan above the base of the prostate. Images reveal markedly dilated bilateral seminal vesicles, loss of normal convolutions (arrows). (B) Seminal vesicle calcification. Axial TRUS showing multiple hyperechoic foci in the bilateral seminal vesicles (arrows). (C) Seminal vesicle cyst. Sagittal and axial TRUS demonstrate a cyst in the right seminal vesicle (arrows). (D) Seminal vesicle cancer. Sagittal view of left seminal vesicle demonstrates a 26-mm ovoid mass (arrows). pressure, and complete examination of the genitalia, including digital rectal examination of the prostate and seminal vesicles. Urine analysis, leukocyte and platelet count, prothrombin time, and activated partial thromboplastin time were routinely performed before TRUS examination. Serum prostatic specific antigen (PSA) was evaluated in patients aged over 40 years. Major illnesses such as coagulation disorders were not found in any patients. The mean age was 41.2 years old (range, years). This study was approved by the ethical committee of Sun Yat-Sen University. Transrectal Ultrasonography The ultrasound machine used in the study was a LOGIQ 400 device (GE Healthcare Technologies, Ultrasound, Milwaukee, Wisconsin) equipped with a biplane transducer with a frequency range of MHz. All patients were examined in the left lateral decubitus position. Seminal vesicles, ejaculatory ducts, prostate, bladder neck, and Cowper glands were scanned with axial and sagittal transducers. Seminal vesicles were examined for pathology, such as dilatation, calcification, cysts, and mass. Ejaculatory ducts were investigated for the presence of dilatation and calculi. The prostate was examined for the presence of calcification, benign prostatic hyperplasia, cystic lesions, inflammation, and tumor. A 12-core systematic biopsy of the prostate was performed in patients suspected of prostate cancer. TRUS-guided biopsy of seminal vesicle masses and cystoscopic examination of bladder tumors were also performed. Seminal vesicle dilatation was considered when its anterioposterior diameter was more than 15 mm (Littrup et al, 1988). Seminal vesicle cysts and calcifications, as well as ejaculatory duct calculi, were determined according to criteria established previously (Fuse et al, 1988; Ganabathi et al, 1992). Ejaculatory duct dilatation was defined if, on a sagittal view, the corresponding duct was markedly dilated on the transverse and sagittal cuts (Worischeck and Parra, 1994). Cysts of the prostate gland were diagnosed according to the updated classification proposed by Galosi et al (2009) as follows: 1) isolated medial cysts, 2) cysts of the ejaculatory duct, 3) simple or multiple cysts of the parenchyma, 4) complicated infectious or hemorrhagic cysts, 5) cystic tumors, 6) cysts secondary to parasitic disease. The percentage of pathologies in the 2 groups of patients more than 40 years old and 40 years old or less were compared. Statistical Analysis Comparison between percentage of pathologies in the 2 groups of patients more than 40 years old and 40 years old or less were performed by chi-square test. A value of P,.05 was considered statistically significant. The statistical analysis was performed with the SPSS 16.0 software package (SPSS, Chicago, Illinois). Results Two hundred fifty-six patients (94.8%) were found to have 1 or more pathological conditions that could cause hematospermia. The percentage of pathological

3 Zhao et al N TRUS in Diagnosis of Hematospermia 899 Figure 2. Transrectal ultrasonography characteristics of ejaculatory duct abnormalities. (A) Ejaculatory duct dilation. Axial and sagittal views showing dilation of the right ejaculatory duct, with a diameter of 3.2 mm (arrows). (B) Ejaculatory duct calculi. Sagittal image demonstrate echogenic foci (arrow) in distribution of right ejaculatory duct. (C) Dilatation of ejaculatory duct accompanied by ejaculatory duct calculi. Sagittal view showing dilation of the ejaculatory duct with calculi in distal part (arrow). conditions located in the seminal vesicles (Figure 1), in the ejaculatory ducts (Figure 2), in the prostate (Figure 3), and in the bladder (Figure 4) were 46.3% (125 cases), 29.6% (80 cases), 55.2% (149 cases), and 0.4% (1 case), respectively (Table 1). No Cowper gland abnormalities were found. The numbers of patients more than 40 years old and 40 years old or less were 126 and 144, respectively. The group of patients more than 40 years old showed significantly higher percentages for malignant diseases (P 5.007), as well as benign prostate abnormalities (P,.001), including prostatic calcification (P,.001) and benign prostatic hyperplasia (P,.001), compared with the group of patients 40 years old or less (Table 2). No significant difference was found between the 2 groups for the percentage of benign seminal vesicle and ejaculatory duct abnormalities, prostatitis, or cysts of the prostate gland. Dilatation of seminal vesicles was accompanied by calcification in seminal vesicles, ejaculatory duct calculi, ejaculatory duct cysts, and isolated medial cysts in 2, 21, 26, and 9 cases, respectively. The diameter of dilated ejaculatory ducts ranged from 1.5 to 4.6 mm (x, 2.3 mm). The largest ejaculatory duct cyst was mm in size. Sole calculus was noted in 19 cases, whereas more than 1 calculus was noted in 15 cases. The long diameter of calculi ranged from 2 to 22 mm (x, 7 mm). Ejaculatory duct dilation was combined with calculi in 25.8% cases (16/62; Figure 2C). TRUS revealed 2 or more abnormalities in 75 patients (27.8%). Malignant tumors were found in 8 of 270 patients (3.0%), including 5 prostate cancers, 2 seminal vesicle cancers, and 1 bladder cancer. All of the malignancies occurred in patients more than 40 years old, and the percentage of malignant diseases was 6.3% in patients more than 40 years old. The 14 patients in which no abnormalities were found by TRUS underwent further magnetic resonance image (MRI) examination, and no causative evidence was discovered.

4 900 Journal of Andrology N September ÙOctober 2012 Figure 3. Transrectal ultrasonography characteristics of prostate abnormalities. (A) Prostatic calcifications. Axial and sagittal images note multiple echogenic foci (arrows) in prostate gland with posterior acoustic shadowing. (B) Benign prostatic hyperplasia. Axial and sagittal images show enlargement of the central gland relative to the peripheral zone, with an associated overall increase in prostatic size and volume. (C) Prostatitis. Axial image reveals diffused hypoechoic foci in peripheral zone suggestive of chronic prostatitis (arrow). (D) Prostate cancer. Axial view demonstrate a hypoechoic lesion in peripheral zone (arrows), in keeping with prostate carcinoma. (E) Axial view show a cyst occurring in the midline of the prostate (short arrow). Sagittal view reveal the cyst starting at the veru montanum and extending above the base of the prostate (long arrow). (F) Ejaculatory duct cyst. Axial and sagittal images show a mm, anechoic, smooth, thin-walled, teardrop-shaped lesion (arrows) in left paramedian location of the prostate gland occurring along the expected course of the ejaculatory duct. Discussion Hematospermia is a relatively frequent, distressing, and frightening symptom in sexually active men. It is typically a cause of great anxiety to men, mainly because of the imagined possibility of underlying malignancy. Hematospermia can arise in association with pathology involving the prostate gland, seminal vesicles, vasa deferentia, ejaculatory ducts, urethra, urinary bladder, epididymides, or testes (Munkel et al, 1997). The detection of the exact cause of hematospermia can help exclude underlying malignancy and reduce the use of empiric antibiotic therapy. Several reports have proved that TRUS is a safe, easily accessible, cost-effective, radiation free, and noninvasive imaging modality that can clearly image seminal vesicles, ejaculatory ducts, and the prostate objectively (Etherington et al, 1990; Amano et al, 1994; Worischeck and Parra, 1994; Yagci et al, 2004). Etherington et al (1990) reviewed 52 patients with hematospermia and found TRUS scan abnormalities in 43 patients (83%), including 32 prostatic calcifications (61.5%), 24 benign prostatic hyperplasias (46.2%), 10 seminal vesicle abnormalities (cyst, dilation, or calculi, 19.2%), and 2 prostatitises (3.8%). Amano et al (1994) performed TRUS in 46 patients with hematospermia and observed similar abnormal findings in 34 patients (73.9%). Worischeck and Parra (1994) reported their experience with 26 patients presenting with hematospermia. In their study, significant sonographic findings were detected in 24 patients (92.3%), consisting of dilated seminal vesicles in 8 (30.8%), ejaculatory duct cysts in 4 (15.4%), ejaculatory or seminal

5 Zhao et al N TRUS in Diagnosis of Hematospermia 901 Table 1. Characteristics of sonographic findings of 270 patients with hematospermia Figure 4. Transrectal ultrasonography characteristics of a bladder tumor. Sagittal view demonstrates a mass with a diameter of 2.5 cm in the bladder neck (arrows). vesicle calculi in 4 (15.4%), ejaculatory duct and seminal vesicle dilatation in 4 (15.4%), seminal vesicle cysts in 2 (7.7%), and Müllerian duct remnants in 2 (7.7%). Yagci et al (2004) performed TRUS in 54 patients. One or more abnormalities were revealed in 51 patients (94.5%). The most common sonographic findings, in order of frequency, consisted of prostatic calcifications (42.6%), ejaculatory duct calculi (38.9%), dilated ejaculatory ducts (33.3%), benign prostatic hyperplasia (33.3%), dilated seminal vesicles (22.2%), calcifications in seminal vesicles (20.4%), ejaculatory duct cysts (11.1%), prostatitises (11.1%), and periurethral Cowper gland masses (1.9%). Probably because the sample size is not large enough and malignant tumors are a rare cause of hematospermia, no patient has been found to have malignancy in any of the mentioned reports. In the present study, significant pathological findings that might cause hematospermia were detected in 256 patients (94.8%); 8 patients (3.0%) were found to have malignant tumors, including 5 prostate cancers, 2 seminal vesicle cancers, and 1 bladder cancer. All the malignancies occurred in patients over 40 years old, and the percentage of malignant diseases was 6.3% in patients over 40 years old. In our series, the most frequent pathological condition of seminal vesicles was dilatation (72.8%), consistent with the finding of Etherington et al (1990). Dilatation and distention of seminal vesicles can result in rupture of mucosal blood vessels. The findings of dilated seminal vesicles on TRUS may represent manifestations of ejaculatory duct obstruction or chronic inflammation (Torigian and Ramchandani, 2007). In this study, dilatation of seminal vesicles was accompanied by pathologies of ejaculatory ducts (calculi, cyst, or dilation) and isolated medial cyst in 65.9% and 9.9%, respectively. Cysts of seminal vesicles are rare, but are frequently Pathological Findings No. of Patients (%) Seminal vesicle abnormalities 125 (46.3) Seminal vesicle dilatation 91 (33.7) Unilateral seminal vesicle dilatation 71 (26.3) Bilateral seminal vesicle dilatation 20 (7.4) Calcifications in seminal vesicles 19 (7.0) Unilateral seminal vesicle calcification 12 (4.4) Bilateral seminal vesicle calcification 7 (2.6) Seminal vesicle cyst 15 (5.6) Seminal vesicle mass 2 (0.7) Ejaculatory duct abnormalities 80 (29.6) Ejaculatory duct dilation 62 (23.0) Ejaculatory duct calculi 34 (12.6) Prostate abnormalities 149 (55.2) Prostatic calcification 106 (39.3) Benign prostatic hyperplasia 71 (26.3) Cysts of the prostate gland 59 (21.9) Ejaculatory duct cyst 38 (14.1) Isolated medial cyst 16 (5.9) Simple cysts of the parenchyma 5 (1.9) Prostatitis 25 (9.3) Prostate tumor 5 (1.9) Bladder tumor 1 (0.4) associated with hematospermia (Worischeck and Parra, 1994). Sometimes seminal vesicle cysts may be acquired from prior infection or inflammation (Mulhall and Albertsen, 1995). In our study, seminal vesicle cysts were found in 5.6% of cases, a finding consistent with the report of Etherington et al (1990; 5.8%). Dilatations of the ejaculatory ducts are usually associated with calculi that could be detected in any region along the ejaculatory ducts (Littrup et al, 1988). In our study, ejaculatory duct dilatation was combined with calculi in 25.8% cases. The correlation between cysts of the prostate gland and hemospermia is not well established. On TRUS, isolated medial cyst typically occur in the midline of the prostate gland, whereas ejaculatory duct cysts usually occur in the paramedian location along the expected course of the ejaculatory duct. The mechanism was probably because of an increase in seminal vesicle intraluminal pressure secondary to compression of the ejaculatory ducts (Furuya and Kato, 2005). In this study, isolated medial cysts were isolated in 7 cases (43.8%) and accompanied by dilatation of seminal vesicles in 9 cases (56.2%). Congenital or acquired cysts of ejaculatory ducts may lead to hematospermia (Worischeck and Parra, 1994). Usually ejaculatory duct cysts are the result of partial distal obstruction of the ejaculatory duct (Ardill et al, 1990). Simple cyst of the prostate parenchyma, also called prostatic retention cyst, is usually observed in the gland as an isolated

6 902 Journal of Andrology N September ÙOctober 2012 Table 2. Percentage of pathologies in 2 groups of patients Pathological Findings.40 y old (n 5 126) (%) #40 y old (n 5 144) (%) P a Total (%) Benign seminal vesicle abnormalities 55 (43.7) 68 (47.2) (45.6) Seminal vesicle dilatation 39 (31.0) 52 (36.1) (33.7) Calcifications in seminal vesicles 10 (7.9) 9 (6.2) (7.0) Seminal vesicle cyst 6 (4.8) 9 (6.2) (5.6) Ejaculatory duct abnormalities 36 (28.6) 44 (30.6) (29.6) Ejaculatory ducts dilation 32 (25.4) 29 (23.0) (23.0) Ejaculatory duct calculi 15 (11.9) 19 (13.2) (12.6) Benign prostate abnormalities 101 (80.2) 43 (30.0), (53.3) Prostatic calcification 75 (59.5) 31 (21.5), (39.3) Benign prostatic hyperplasia 71 (56.3) 0 (0), (26.3) Cysts of the prostate gland 30 (23.8) 29 (20.1) (21.9) Prostatitis 14 (11.1) 11 (7.6) (9.3) Malignant diseases 8 (6.3) 0 (0).007 b 8 (3.0) a Comparisons between the 2 groups were performed by chi-square test. b P value after continuity correction. lesion surrounded by normal tissue, and its TRUS features are an anechoic content with thin and smooth walls or hairline septa (Galosi et al, 2009). Hematospermia can also be caused by prostatic calcification. It is possible that the cause of hematospermia arises from mechanical trauma to the prostatic duct by intraductal calcification during ejaculation (Etherington et al, 1990). In this study, prostatic calcifications were noted in 40% of cases, a finding lower than that found by Etherington et al (1990; 61.5%) but higher than the report of Amano et al (1994; 37%). Chronic prostatitis is a chronic inflammatory condition of the prostate gland. However, the relation between prostatitis and hematospermia has not been thoroughly evaluated (Yagci et al, 2004). Three reported incidences of prostatitis in patients with hematospermia were 3.8%, 11%, and 23% (Etherington et al, 1990; Yagci et al, 2004; Fuse et al, 1988). In our study, 25 (9.3%) cases showed signs of prostatitis on TRUS. Benign prostatic hyperplasia is frequently encountered in patients over the age of 40 years. However, it is debatable whether benign prostatic hyperplasia can be regarded as a cause of hematospermia (Yagci et al, 2004). Compared with the group of patients 40 years old or less, the group of patients more than 40 years old showed significantly higher percentages for prostatic calcification and benign prostatic hyperplasia. The difference might be interpreted by the fact that prostatic calcification and benign prostatic hyperplasia are age-related pathological changes (Untergasser et al, 2005). Cowper gland abnormalities are rarely reported to have an association with hematospermia. Yagci et al (2004) reported a mass of Cowper gland that might be the causative factor for hematospermia. Unfortunately, the patient refused to undergo histopathological examination. In our study, no Cowper gland abnormalities were revealed by TRUS. Malignant tumors are rarely associated with hematospermia. A review of the English literature from 1966 to 2006 identified a total of 33 (3.5%) tumors in 931 cases in etiological studies of hematospermia (Ahmad and Krishna, 2007). Of the 33 tumors identified in those series, 25 were of prostatic origin, the remaining tumors were in the seminal vesicle in 6 patients, the testicle in 1 patient, and epididymis in 1 patient. All of these patients were more than 40 years old. Referring to the presented data, we compared the percentages of both malignant and benign pathologies between the 2 groups of patients (40 years and younger and more than 40 years old). In our study, 8 (3%) malignant tumors were found, including 5 prostate cancers, 2 seminal vesicle cancers, and 1 bladder cancer, a finding consistent with the mentioned review. Notably, these 8 patients accounted for 6.3% of hematospermia patients more than 40 years old. Therefore, to rule out other diseases, in particular neoplasm, we recommend a published diagnostic process to evaluate patients aged over 40 years as follow: 1) history and physical examination, 2) laboratory studies, especially serum PSA, 3) TRUS examination, 4) MRI or further invasive methods, such as prostate biopsy, cystoscopy, or puncture of seminal vesicles according to the corresponding TRUS abnormalities; periodic follow-up is recommended, with no TRUS abnormalities revealed (Szlauer and Jungwirth, 2008). To the best of our knowledge, no study has revealed bladder cancer associated with hematospermia. In that case, a mass with a diameter of 2.5 cm was found in the bladder neck. Because no other findings were made that might cause hematospermia, bladder cancer might be the causative factor for hematospermia.

7 Zhao et al N TRUS in Diagnosis of Hematospermia 903 MRI is another noninvasive imaging method that was shown to be helpful in the evaluation of hematospermia. The reported abnormal MRI findings vary from 57% to 93% of hematospermia cases (Maeda et al, 1993; Hasegawa et al, 1998). Szlauer and Jungwirth (2008) concluded that MRI is the method of choice when TRUS does not yield usable results. In this study, the 14 patients for which no abnormalities were found by TRUS underwent further MRI examination. However, no causative evidence was discovered by MRI. TRUS can also be used as a guide for treatment of hematospermia if certain treatable underlying pathologies are coincidentally detected. Transurethral incision of ejaculatory duct is a problem-solving approach to treat hematospermia because of obstruction by either a stone or a prostatic cyst (Fuse et al, 2003; Manohar et al, 2008). It is also important to know the distance between the posterior wall of the prostatic urethra and the wall of the ducts or the midline prostatic cyst before undertaking an incision. TRUS can be used to appreciate these anatomical relationships and to assist with the therapeutic incision (Manohar et al, 2008). Hematospermia is generally a benign symptom in younger patients. Special attention should be paid to patients more than 40 years old to exclude malignancy. TRUS can suggest a cause of hematospermia in the majority of patients without resorting to invasive or expensive investigations, as well as exclude malignancy of the prostate and seminal vesicles. TRUS is a noninvasive, reliable tool for the investigation of causes of hematospermia. References Ahmad I, Krishna NS. Hemospermia. J Urol. 2007;177: Amano T, Kunimi K, Ohkawa M. Transrectal ultrasonography of the prostate and seminal vesicles with hemospermia. Urol Int. 1994;53: Ardill RH, Manivel JC, Beier-Hanratty S, Ercole C, Letourneau JG. Epididymitis associated with Müllerian duct cyst and calculus: sonographic diagnosis. Am J Roentgenol. 1990;155: Etherington RJ, Clements R, Griffiths GJ, Peeling WB. Transrectal ultrasound in the investigation of hematospermia. Clin Radiol. 1990;41: Furuya S, Kato H. A clinical entity of cystic dilatation of the utricle associated with hemospermia. J Urol. 2005;174: Fuse H, Nishio R, Murakami K, Okumura A. Transurethral incision for hematospermia caused by ejaculatory duct obstruction. Arch Androl. 2003;49: Fuse H, Sumiya H, Ishii H, Shimazaki J. Treatment of hematospermia caused by dilated seminal vesicles by direct drug injection guided by ultrasonography. J Urol. 1988;140: Galosi AB, Montironi R, Fabiani A, Lacetera V, Gallé G, Muzzonigro G. Cystic lesions of the prostate gland: an ultrasound classification with pathological correlation. J Urol. 2009;181: Ganabathi K, Chadwick D, Fenely RCL, Gingell JC. Hematospermia. Br J Urol. 1992;69: Hasegawa N, Miki K, Kato N, Furuta N, Ohishi Y, Kondo N, Tashiro K. Magnetic resonance images of hematospermia. Nippon Hinyokika Gakkai Zasshi. 1998;89: Littrup PJ, Lee F, McLeary RD, Wu D, Lee A, Kumasaka GH. Transrectal US of the seminal vesicles and ejaculatory ducts: clinical correlation. Radiology. 1988;168: Maeda H, Toyooka N, Kinukawa T, Hattori R, Furukawa T. Magnetic resonance images of hematospermia. Urology. 1993;41: Manohar T, Ganpule A, Desai M. Transrectal ultrasound- and fluoroscopic-assisted transurethral incision of ejaculatory ducts: a problem-solving approach to nonmalignant hematospermia due to ejaculatory duct obstruction. J Endourol. 2008;22: Mulhall JP, Albertsen PC. Hemospermia: diagnosis and management. Urology. 1995;46: Munkel witz R, Krasnokutsky S, Lie J, Shah SM, Bayshtok J, Khan SA. Current perspectives on hematospermia: a review. J Androl. 1997;18:6 14. Szlauer R, Jungwirth A. Haematospermia: diagnosis and treatment. Andrologia. 2008;40: Torigian DA, Ramchandani P. Hematospermia: imaging findings. Abdom Imaging. 2007;32: Untergasser G, Madersbacher S, Berger P. Benign prostatic hyperplasia: age-related tissue-remodeling. Exp Gerontol. 2005;40: Worischeck JH, Parra RO. Chronic hematospermia: assessment by transrectal ultrasound. Urology. 1994;43: Yagci C, Kupeli S, Tok C, Fitoz S, Baltaci S, Gogus O. Efficacy of transrectal ultrasonography in the evaluation of hematospermia. Clin Imaging. 2004;28: