Men's Health: Detailed Explanation of the Causes, Diagnosis, and Treatment of Hematospermia and Priapism

Hematospermia (blood in semen)

Normal semen is milky white or milky yellow. If the ejaculated semen contains red blood cells, and its color is pink, red, brownish-red, or streaked with blood, it is called hematospermia.

The most common cause of hematospermia is seminal vesiculitis. The seminal vesicles are located above the prostate gland, between the bladder and rectum. Their ends merge with the ends of the vas deferens to form the ejaculatory ducts, which lead to the urethra. Secretions from the seminal vesicles contribute to the composition of semen. Because the seminal vesicles are adjacent to the prostate, urinary tract, and rectum, when these organs are inflamed, bacteria can easily spread to the seminal vesicles, causing inflammation and swelling and congestion of the seminal vesicle walls. The seminal vesicle wall contains a layer of tiny blood vessels, which are easily injured and can cause bleeding. Therefore, in addition to hematospermia during sexual intercourse, it may also be accompanied by mild perineal, rectal, and lower abdominal pain, or symptoms of urinary tract infection such as painful urination. Therefore, whenever a patient complains of hematospermia, a semen analysis should be performed. Microscopic examination will reveal a large number of red blood cells, or a routine examination of prostatic fluid will confirm the diagnosis. Treatment should be based on prostatitis and seminal vesiculitis. Once hematospermia occurs, sexual activity should be stopped, and sulfonamides or antibiotics should be used for anti-inflammatory treatment. Doctors sometimes use seminal vesicle and prostate massage to empty the bacterial-containing fluid from the seminal vesicles as soon as possible to facilitate recovery. Some advocate abstaining from sexual activity to allow the bacterial-containing fluid from the seminal vesicles to be expelled with ejaculation. In elderly men with hematospermia, the possibility of tumors should be considered, and a semen pathological examination may be performed if necessary to rule out tumors.

Priapism

Priapism is a persistent, painful swelling of the corpora cavernosa of the penis that can occur in men of any age. In recent years, with the development of clinical drug treatment and the diagnosis and treatment of male sexual dysfunction, priapism has become increasingly common as a urological emergency. Timely and effective treatment is of great significance for the recovery of the patient's sexual function.

(I) Causes of Priapism

Many systemic diseases can cause priapism, with hematological disorders being a common cause. Examples include sickle cell disease, thalassemia, polycythemia vera, and thrombocytopenia. Especially in children, approximately 60% of priapism cases are the first symptom of a hematological disorder. Therefore, in addition to a thorough urological examination, patients with priapism should undergo hematological examinations to rule out the possibility of hematological disorders.

Drug-induced priapism is a relatively common clinical cause, accounting for about 30% of cases. Many drugs can cause priapism, such as antihypertensive drugs, antidepressants, vasodilators, and anesthetics. Priapism caused by vasoactive drugs occurs because the drug blocks α-receptors, reducing the excitability of the sympathetic nervous system and increasing the excitability of the parasympathetic nervous system in the erectile tissue. This leads to sustained and sufficient dilation of arteries, causing a large influx of blood into the erectile tissue, resulting in priapism. Prazosin, an alpha-receptor blocker, lowers blood pressure by dilating arteries and is commonly used to treat hypertension. Numerous reports in the literature document priapism (excessive erectile dysfunction) in patients treated with this drug for hypertension. In recent years, papaverine injection into the corpora cavernosa has become increasingly common in the treatment of erectile dysfunction, leading to a rise in priapism. We recently encountered a 27-year-old patient who, after experiencing unsatisfactory erections following marriage, underwent papaverine injection into the corpora cavernosa, resulting in painful erections lasting up to a week. This was subsequently cured through heparinized saline corpora cavernosa irrigation and surgical shunt. There are also many reports in the literature of priapism caused by the use of vasoactive drugs to treat erectile dysfunction. Certain antihypertensive drugs, such as guanethidine and reserpine, can deplete adrenaline in erectile tissue, causing vasodilation and leading to priapism. The antidepressants phenothiazines and butyrophenones have strong vasodilatory effects and can cause priapism in some patients. Hemostatic agents and anticoagulants can also cause priapism. Long-term use of hemostatic agents can increase blood viscosity, slow blood flow, and easily lead to microthrombus formation, resulting in priapism. Priapism caused by anticoagulants generally occurs during the intervals between medication use, because the blood is in a hypercoagulable state after discontinuation of anticoagulants, making it prone to blood stasis and causing priapism. Literature has reported some patients experiencing priapism due to intermittent heparin use. Intramuscular injection of testosterone generally has no obvious side effects; however, in some more sensitive patients, conventional doses of testosterone can also lead to prolonged erections. One case reported involved a patient with delayed puberty who experienced priapism after testosterone treatment. Other drugs such as diazepam, benzodiazepines, alcohol, and marijuana can also cause priapism to varying degrees. Damage to the central and peripheral nervous systems, such as spinal cord injuries, pelvic trauma, and local lesions like pelvic abscesses, inflammation, hemangiomas, and tuberous sclerosis, can cause abnormalities in the nerve conduction system innervating erectile tissue, leading to priapism. Damage to the nerve conduction system in diabetic patients can cause impotence, but it can also cause priapism. Priapism in patients with renal failure and uremia is believed to be related to the intermittent use of heparin during hemodialysis, but priapism can also occur in patients not using heparin, although the mechanism is not fully understood.

Besides secondary priapism caused by the above reasons, some patients have no identifiable clinical cause, termed primary or idiopathic priapism. Idiopathic priapism accounts for almost 50% of cases. In some patients, it may be due to prolonged sexual stimulation leading to blood pooling in the erectile tissue.

(II) Diagnosis Clinical diagnosis of priapism is not difficult; a definitive diagnosis can be made based on medical history and clinical examination. It is crucial to determine the cause of priapism. This requires the attending physician to take a detailed medical history, comprehensively understanding the patient's onset, whether any medications were taken, and any specific history of sexual stimulation. A thorough clinical physical examination and comprehensive laboratory tests are necessary. The patient should provide the doctor with detailed information about their condition before the onset of the priapism. During the physical examination, attention should be paid to the presence of urinary retention, perineal masses, total trauma or neurological dysfunction, and the presence of systemic or local infections. Laboratory tests should be as comprehensive as possible. Systematic blood analysis can rule out sickle cell disease or other blood disorders. Blood biochemistry and electrolyte, urea nitrogen, creatinine, and blood glucose tests will help in identifying the cause. Some have suggested performing penile cavernous body blood gas analysis to differentiate between low-flow and high-flow erections. Low penile blood flow patients have PO₂ below normal and PCO₂ above normal, experiencing severe local pain. Without timely treatment, the prognosis is poor. High penile blood flow patients have relatively normal PO₂ and PCO₂, milder local pain, and a better prognosis. Doppler penile blood flow measurement helps observe changes in penile blood flow before and after treatment. Internal pudendal artery angiography is helpful for both diagnosis and treatment.

(III) Treatment

1. General Treatment: Stabilizing the patient's emotions and alleviating their anxiety is an important means to promote treatment. Sedatives, analgesics, local cold compresses, ice-saline enemas, prostate massage, and intravenous infusions may be used as appropriate. Symptoms may gradually improve in some patients after these treatments.

2. Drug Treatment: Anesthetics can be used. A mixture of 1% novocaine and 2% lidocaine can be used for penile root block anesthesia, sacral anesthesia, spinal anesthesia, or epidural anesthesia. This method often relieves the condition of some patients. Some reports indicate that ketamine treatment can alleviate symptoms in 50% of patients. This drug should be used under the guidance and close observation of an anesthesiologist. Vasoactive drugs can be used to lower blood pressure in young patients without cardiovascular disease to reduce blood flow into the corpora cavernosa. Blood pressure changes must be closely controlled and monitored; caution should be exercised in elderly patients. A 1:100,000 norepinephrine saline irrigation treatment can also be used. Dissolve 1 mg of norepinephrine in 1000 ml of normal saline, inject 20-30 ml into the corpora cavernosa, aspirate after 2-3 minutes, and repeat until the penis becomes flaccid.

3. Targeted Treatment: For patients with obvious triggers, in addition to the above treatments, attention should be paid to treating the underlying cause to eliminate the direct cause of priapism. For cases caused by sickle cell disease, transfusion of fresh blood or alkaline drugs to alkalize the blood often relieves symptoms; for those caused by tumors, chemotherapy and radiotherapy can promote symptom relief; for those caused by medications, the medication should be discontinued immediately and antagonistic drugs should be used to promote symptom relief; for those caused by hypercoagulable states during anticoagulation therapy intervals, anticoagulation therapy should be continued.

4. Surgical Treatment: If the patient's symptoms do not improve after the above conservative treatments, surgical treatment should be performed promptly and decisively. Surgical shunt methods include: penile cavernous body to urethral sponge body shunt; penile glans to corpus cavernosum shunt; penile dorsal vein to corpus cavernosum shunt; great saphenous vein to corpus cavernosum shunt; femoral artery catheterization and pudendal artery embolization, etc.