今日の臨床サポート

血精液症

著者: 井上貴昭1) 原泌尿器科病院

著者: 松田公志2) 関西医科大学 泌尿器科学教室

監修: 松田公志 関西医科大学 泌尿器科学教室

著者校正/監修レビュー済:2016/06/10
患者向け説明資料

概要・推奨   

  1. 血精液症とは、伝統的に、射精した精液のなかに肉眼的な血液が存在することと定義されている。正常男性にとって血精液症が繰り返されることは不安を駆り立てる要因である。
  1. 多くの血精液症の原因は良性の炎症であるが、まれにこの症状が泌尿器科癌に現れる最初の症状の場合もある。初めて血精液症が出現したときの年齢を確認する。(患者はしばしば、病院を受診する以前にも同症状を伴っていることがある。40歳未満では悪性腫瘍が原因のことは少ない。
  1. 40歳未満の患者の場合は、悪性腫瘍が原因である可能性は少ないが、40歳以上の場合には悪性腫瘍を含めた精査が必要である。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
井上貴昭 : 特に申告事項無し[2021年]
松田公志 : 講演料(アステラス製薬株式会社),奨学(奨励)寄付など(小野薬品工業株式会社)[2021年]
監修:松田公志 : 講演料(アステラス製薬株式会社),奨学(奨励)寄付など(小野薬品工業株式会社)[2021年]

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 血精液症は従来、射精した精液のなかに肉眼的に確認できる血液が存在することと定義されている。
  1. 1894年に、Huguesらが血精液症について報告したのが最初である。この症状は比較的まれであり、短期間で消失することも多く、self-limitingな場合も多い。そのため、血精液症を持つ男性患者の77.5%は、泌尿器科を受診する前に1~2回の血精液症のエピソードを経験していることも少なくない。 解説 
  1. しかし、正常男性にとって血精液症が繰り返されることは不安を駆り立てる要因である。多くの血精液症の原因は良性であるが、まれにこの症状が泌尿器科癌に現れる最初の症状の場合もある。Hanらは、50歳以上の男性2万6,126人に前立腺癌のスクリーニング検査を行い、139人(0.5%)に血精液症の既往を認めたと報告し、その血精液症の既往を持つ男性のうち19人(14%)が前立腺癌であったと報告している。 解説 
  1. 近年の画像技術の急速な進歩により、今まで特発性血精液症と診断されてきた多くの症例が劇的に減少すると考えられる。しかし、血精液症の患者を詳細に評価したような研究報告はあまり多くない。今もなお、このような血精液症の患者の原因をどのように調べればいいのかという課題は残っている。
問診・診察のポイント  
  1. 血精液症患者への診断アプローチは、治療可能な原因疾患を見逃さないために系統的に行われるべきである。原因疾患は多岐にわたるため、全身的な検索が必要となってくる。

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文献 

著者: V F Marshall, N L Fuller
雑誌名: J Urol. 1983 Feb;129(2):377-8.
Abstract/Text
PMID 6601197  J Urol. 1983 Feb;129(2):377-8.
著者: D J Jones
雑誌名: Br J Urol. 1991 Jan;67(1):88-90.
Abstract/Text A prospective study of 74 men with haemospermia is presented. Most (76%) had experienced 1 or 2 episodes only and 9 (12%) were over 40 years old. Simple investigations led to a diagnosis in all 9 of these men and of those under 40, no pathology could be detected in 48%. A diagnosis was made in 32 of the remaining 34 men by simple investigations. In patients over 40 years of age with haemospermia, a potentially treatable cause will normally be found by routine investigation which should include cystoscopy. In younger men, non-invasive investigation alone should identify any pathology. Invasive investigations should be reserved for those patients in whom the problem is prolonged, excessive or in association with other symptoms.

PMID 1704278  Br J Urol. 1991 Jan;67(1):88-90.
著者: Misop Han, Robert E Brannigan, Jo Ann V Antenor, Kimberly A Roehl, William J Catalona
雑誌名: J Urol. 2004 Dec;172(6 Pt 1):2189-92.
Abstract/Text PURPOSE: Hemospermia is uncommon clinical condition that usually follows a benign course. The association between hemospermia and prostate cancer has been reported but to our knowledge not thoroughly investigated. We studied the incidence of hemospermia and the association between prostate cancer and hemospermia in a large prostate cancer screening population.
MATERIALS AND METHODS: Between 1991 and 2001, 26,126 ambulatory men 50 years or older (40 years or older with a family history of prostate cancer or black race) underwent a community based prostate cancer screening study using serum prostate specific antigen (PSA) and digital rectal examination (DRE). PSA measurement and DRE were repeated at 6-month or 1-year intervals depending on PSA for the remainder of the study. Men underwent prostate biopsy due to increased serum PSA (greater than 4.0 ng/ml until May 1995 or greater than 2.5 ng/ml after May 1995) or suspicious DRE. Men with a history of prostate cancer were excluded from study. Men completed a questionnaire, including information about hemospermia, at each screening visit. Hemospermia information from the initial questionnaire was analyzed. The relative risk of prostate cancer diagnosis in the overall prostate cancer screening population and the cohort with hemospermia was determined. Detailed prostate cancer characteristics were evaluated in those who had hemospermia and underwent radical prostatectomy. We used a multivariate logistic regression model to test the independent significance of hemospermia after adjusting for other known predictors of prostate cancer detection.
RESULTS: Prostate cancer was detected in 1,708 of the 26,126 men (6.5%) who underwent prostate cancer screening. Prostate cancer was diagnosed in 19 of the 139 men (13.7%) who reported hemospermia upon entering the prostate cancer screening study. The median age of the 139 men was 61 years (range 40 to 89). Ten of the 13 men who underwent radical retropubic prostatectomy had stage pT2 disease, while 3 had stage pT3 disease. In the logistic regression model hemospermia was a significant predictor of prostate cancer diagnosis after adjusting for age, PSA and DRE results (OR 1.73, p = 0.054).
CONCLUSIONS: Hemospermia is rare (0.5%) in a prostate cancer screening population. When a man presents with hemospermia, prostate cancer screening should be vigilantly performed since hemospermia is associated with an increased risk of prostate cancer.

PMID 15538229  J Urol. 2004 Dec;172(6 Pt 1):2189-92.
著者: R Munkel witz, S Krasnokutsky, J Lie, S M Shah, J Bayshtok, S A Khan
雑誌名: J Androl. 1997 Jan-Feb;18(1):6-14.
Abstract/Text Hematospermia is a disconcerting symptom that produces extreme anxiety in sexually active male patients. To understand the pathophysiology of hematospermia, the anatomy of the ejaculatory system and neurophysiology of emission and ejaculation is essential. Emission and ejaculation must be present for hematospermia to occur. Hematospermia may be the result of inflammation, infection, ductal obstruction or cysts, neoplasms, vascular abnormalities, and systemic or iatrogenic factors. Most patients promptly consult a urologist after an episode of hematospermia. History and physical examination are often unrevealing and the judicious use of imaging modalities, such as transrectal ultrasound, MRI, and rigid or flexible endoscopy may be diagnostic. Unless the specific etiology is defined, most cases are managed expectantly. We review the etiology of hematospermia and an algorithm is provided for the diagnosis and management.

PMID 9089062  J Androl. 1997 Jan-Feb;18(1):6-14.
著者: G K Papp, Z Kopa, F Szabó, E Erdei
雑誌名: Andrologia. 2003 Oct;35(5):317-20.
Abstract/Text There are several unknown factors which cause haemospermia. An earlier developed diagnostic scheme has been expended by novel imaging techniques and biopsy methods. A detailed case history, physical examination and microscopic analysis of the ejaculate is required. In haemo-pyospermia a complete microbiological analysis must be escalated. Noninvasive imaging techniques (ultrasound, computer tomography and magnetic resonance imaging) help in detecting calculous and malignant diseases. So far, as a precise diagnosis has not been available, urethroscopy has been performed. Malignancies (prostate, seminal vesicles) must be histologically verified by biopsies. In contempt of our efforts the practice shows a part of haemospermia remaining essential. Analysing two time periods we found prostatic calculi, chronic prostatitis and carcinoma of the prostate unequivocally as most frequent causes. Considering the rare genital malignancies we find more than 10% frequency. Notably, in our study only 2.4% of the malignancies occurred in patients under 40 years of age. Hence a detailed diagnosis is advocated in haemospermia patients over 40 years. Finally, we may state that in contempt of the applied modern imaging techniques 15% of patients with haemospermia had unknown aetiology.

PMID 14535863  Andrologia. 2003 Oct;35(5):317-20.
著者: K Ganabathi, D Chadwick, R C Feneley, J C Gingell
雑誌名: Br J Urol. 1992 Mar;69(3):225-30.
Abstract/Text Haemospermia is a frightening symptom. Many cases are of benign aetiology but 5 to 10% will have underlying malignancy. Many younger patients require only routine clinical examination, urine analysis and reassurance, but patients aged over 40 years, those with persistent haemospermia, or those with associated haematuria require urological investigation. Imaging of the prostate and seminal vesicles with transrectal ultrasound is of particular value in the investigation of these patients.

PMID 1568093  Br J Urol. 1992 Mar;69(3):225-30.
著者: S Jinza, K Noguchi, M Hosaka
雑誌名: Hinyokika Kiyo. 1997 Feb;43(2):103-7.
Abstract/Text A retrospective study on 107 men with hematospermia between 1986 and 1993 is reported. The age of the patients ranged from 16 to 73 years (mean 45.6 years). Sixty five patients (60.7%) were asymptomatic except for hematospermia. Hematospermia disappeared within one month in 43% of all the patients, and in 61% of those under 40 years of age. Thirty four patients had urological diseases; 15 patients had chronic prostatitis, 10 benign prostatic hyperplasia, 3 prostatic calculi, 1 genital tuberculosis, 1 prostate cancer, and 4 other diseases. Hematospermia was ascribed to hypertension in another 5 patients. However, the cause of hematospermia was not apparent in 79% of the patients under 40. We recommend a routine physical examination to detect infectious or inflammatory lesions, in younger patients with transient hematospermia whereas a through urological screening for more serious urogenital diseases, and measurement of blood pressure in older patients especially those with persistent hematospermia.

PMID 9086344  Hinyokika Kiyo. 1997 Feb;43(2):103-7.
著者: T Amano, K Kunimi, M Ohkawa
雑誌名: Urol Int. 1994;53(3):139-42.
Abstract/Text Transrectal ultrasonography was performed in 46 patients with hemospermia. Abnormal findings in the prostate and seminal vesicles, including prostatic stones, benign prostatic hyperplasia, prostatitis, and dilatation and calculi of the seminal vesicles, were observed in 34 patients (73.9%). However, no malignant lesions were found in the prostate or seminal vesicles. Transrectal ultrasonography was a useful and noninvasive procedure to investigate the causes of hemospermia. Furthermore, transrectal ultrasonography could demonstrate latent diseases and exclude malignancy of the prostate and seminal vesicle in patients with hemospermia.

PMID 7645140  Urol Int. 1994;53(3):139-42.
著者: Cemil Yagci, Sadettin Kupeli, Cisel Tok, Suat Fitoz, Sumer Baltaci, Orhan Gogus
雑誌名: Clin Imaging. 2004 Jul-Aug;28(4):286-90. doi: 10.1016/S0899-7071(03)00157-8.
Abstract/Text OBJECTIVE: To assess the efficacy of transrectal ultrasonography (TRUS) in the evaluation of hematospermia.
MATERIAL AND METHODS: This study included 54 patients with hematospermia. Patients age range was between 25 and 75 years (mean=49.7 years). All patients were evaluated by TRUS using a biplane transducer and a Toshiba SSA-270A device.
RESULTS: TRUS revealed one or more abnormalities in 51 patients (94.5%). Prostatic calcifications were found in 23 patients, ejaculatory duct calculi in 21, dilated ejaculatory ducts in 18, benign prostatic hyperplasia in 18, dilated seminal vesicles in 12, calcifications in seminal vesicles in 11, ejaculatory duct cyst in 6, prostatitis in 6, and periurethral Cowper gland mass in 1.
CONCLUSION: TRUS is a noninvasive, safe method for the investigation of causes of hematospermia. We believe that it should be the first radiological investigation to be performed in patients presenting with hematospermia.

PMID 15246480  Clin Imaging. 2004 Jul-Aug;28(4):286-90. doi: 10.1016/S・・・
著者: H Maeda, N Toyooka, T Kinukawa, R Hattori, T Furukawa
雑誌名: Urology. 1993 May;41(5):499-504.
Abstract/Text Seminal vesicles and their adjacent structures were studied using magnetic resonance imaging (MRI) in 7 normal volunteers and 15 patients with hematospermia. Normal seminal vesicles are depicted on T2-weighted images either as a mixture of high- and low-signal granules or as a convolution of tubules with a diameter of less than 0.5 cm. Fourteen of the 15 patients with hematospermia exhibited abnormalities on MRI. Dilatation or cyst formation in the seminal vesicle was observed in 13 patients, and a dilatation of the midline structure was seen in 3 patients. Abnormal signal intensity of the seminal vesicles was seen in 11 patients and was thought to be due to subacute hemorrhage.

PMID 8488623  Urology. 1993 May;41(5):499-504.
著者: Imran Ahmad, Nalagatla Sarath Krishna
雑誌名: J Urol. 2007 May;177(5):1613-8. doi: 10.1016/j.juro.2007.01.004.
Abstract/Text PURPOSE: With current diagnostic modalities the proportion of patients diagnosed with idiopathic hemospermia has decreased dramatically. The dilemma now is how far to investigate these patients since in the majority it is a benign and self-limiting symptom.
MATERIALS AND METHODS: We reviewed the literature on hemospermia with particular emphasis on etiology, diagnosis and management. A Medline search of the literature for the last 40 years was done and all relevant articles were studied in full.
RESULTS: Etiological factors are often categorized into the various pathophysiological mechanisms. Most cases of hemospermia are the result of iatrogenic, inflammatory and infective pathologies. A literature review of the etiological studies of hemospermia identified a total of 33 tumors (25 prostatic) in 931 cases (3.5%). In patients younger than 40 years an infective cause in the urogenital tract is the most common etiological factor. Often only simple, tailored investigations and appropriate treatment are required. In patients older than 40 years with persistent hemospermia or associated symptoms such as hematuria it is essential to exclude urogenital malignancy. History, examination and simple investigation should also suffice in this group. If the diagnosis is still unclear, further investigation in the form of transrectal ultrasound, magnetic resonance imaging and cystoscopy is of proven benefit. Treatment for hemospermia depends on the underlying pathological condition. In most cases bleeding is slight and self-limited, and it may be managed expectantly.
CONCLUSIONS: The majority of patients can be treated with minimal investigations and simple reassurance. In older patients or those with persistent hemospermia or associated symptoms modern diagnostic techniques are of proven benefit.

PMID 17437771  J Urol. 2007 May;177(5):1613-8. doi: 10.1016/j.juro.200・・・
著者: R Szlauer, A Jungwirth
雑誌名: Andrologia. 2008 Apr;40(2):120-4. doi: 10.1111/j.1439-0272.2007.00821.x.
Abstract/Text Men perceive a bloody ejaculate as an alarming physical symptom and often seek the help of urologists for explanation and treatment. After a complete urological step-by-step examination including imaging studies and flexible cystoscopy, malignancy or another significant disease can be ruled out in the majority of cases. However, many of these cases of haematospermia may still remain idiopathic and thus unsatisfactory for both the patient and his physician. The following paper reviews the aetiology, the diagnostic work-up escalation and the treatment options of haematospermia.

PMID 18336463  Andrologia. 2008 Apr;40(2):120-4. doi: 10.1111/j.1439-0・・・
著者: Priya Kumar, Sona Kapoor, Vinod Nargund
雑誌名: Ann R Coll Surg Engl. 2006 Jul;88(4):339-42. doi: 10.1308/003588406X114749.
Abstract/Text Haematospermia (or haemospermia) is a distressing symptom in sexually active men. In most cases, it is caused by non-specific inflammation of the prostate and seminal vesicles. In a small percentage of men, however, it may be a manifestation of genito-urinary or systemic malignancy, in particular prostate cancer. The purpose of this review is to explain the causes and management of patients with haematospermia.

PMID 16834849  Ann R Coll Surg Engl. 2006 Jul;88(4):339-42. doi: 10.13・・・
著者: J P Mulhall, P C Albertsen
雑誌名: Urology. 1995 Oct;46(4):463-7.
Abstract/Text
PMID 7571212  Urology. 1995 Oct;46(4):463-7.
著者: P Maheshkumar, U Otite, S Gordon, D M Berney, V H Nargund
雑誌名: J Urol. 2001 Jan;165(1):188. doi: 10.1097/00005392-200101000-00050.
Abstract/Text
PMID 11125399  J Urol. 2001 Jan;165(1):188. doi: 10.1097/00005392-2001・・・
著者: Xiao-Cheng Wu, Vivien W Chen, Brooke Steele, Steven Roffers, Judith B Klotz, Catherine N Correa, Susan E Carozza
雑誌名: J Adolesc Health. 2003 Jun;32(6):405-15.
Abstract/Text PURPOSE: To examine cancer incidence patterns among adolescents and young adults in the United States.
METHODS: Cancer incidence data from 26 population-based central cancer registries for 1992-1997 were used. Individual cancers were grouped into specific diagnostic groups and subgroups using an integrated classification scheme. The integrated scheme was developed for this study and was based on the most commonly used schemes in population-based epidemiologic studies: Surveillance, Epidemiology, and End Results Program's site groups, International Classification of Childhood Cancer, and International Agency for Research on Cancer's Histological Groups for Comparative Studies. Percent distributions and age-specific incidence rates per million population were computed for adolescents (aged 15-19 years) and young adults (aged 20-24 years) by gender.
RESULTS: The data for 26,010 cancer cases were examined. Among 15-19-year-olds, the five most common cancers were Hodgkin's disease, leukemia, cancer in the brain and other nervous system, bone cancer, and non-Hodgkin's disease. Among 20-24-year-olds, the five most common cancers were Hodgkin's disease, testicular cancer, thyroid cancer, melanoma of the skin, and leukemia. The proportions and rates of the histologic subtypes for most of the common cancers changed with advancing age. For example, among 15-19-year-olds, acute lymphocytic leukemia accounted for approximately 60% of leukemias in males and 50% in females. Among 20-24-year-olds, however, the corresponding percentages of acute lymphocytic leukemia were 37% in males and 31% in females. For ovarian cancer, the germ cell tumor was the most common subtype (54.6% of all ovarian cancers) among 15-19-year-olds. In contrast, ovarian carcinoma was the predominant subtype (70.4%) among 20-24-year-olds. For both age groups, the incidence rates of nodular Hodgkin's disease, melanoma of the skin, and thyroid cancer were significantly greater in females than in males.
CONCLUSIONS: Cancer incidence patterns among adolescents and young adults are distinctive. In these age groups, a transition from predominantly pediatric histologic subtypes to adult subtypes was observed for Hodgkin's disease, leukemia, ovarian cancer, and soft tissue sarcoma. Gender differences were found for Hodgkin's disease, melanoma of the skin, and thyroid cancer.

PMID 12782451  J Adolesc Health. 2003 Jun;32(6):405-15.
著者: Dean E Leocádio, Barry S Stein
雑誌名: Int Urol Nephrol. 2009;41(1):77-83. doi: 10.1007/s11255-008-9409-9. Epub 2008 Jun 19.
Abstract/Text BACKGROUND: Hematospermia, or blood in the ejaculate, usually follows a benign self-limiting course. However, it can be a source of considerable anxiety in patients. The purpose of this article is to provide the primary care physician an algorithm for the evaluation and management of hematospermia based on frequency of occurrence and patient age.
METHODS: We performed an English language MEDLINE (1966 to present) search for the terms hematospermia, hemospermia, management, prostate biopsy and combinations thereof. We then constructed a management algorithm based on available evidence.
RESULTS: Typically, patients present to their primary care physician after a single episode of hematospermia out of concern for malignancy or venereal disease. In men 40 years old or younger, it is most often due to inflammatory or infectious processes. In men over 40 years of age, however, an association exists between hematospermia and more serious underlying pathology. A significant number of cases remain idiopathic even after extensive investigation.
CONCLUSIONS: Hematospermia is an anxiety-provoking sign that is usually due to inflammatory or infectious causes. Recurrent or symptomatic hematospermia may herald more serious underlying pathology, especially in those patients over 40 years old. A thorough evaluation is warranted to both rule out more serious pathology and to adequately address patient anxiety. With modern imaging techniques, the number of "idiopathic" cases should be much lower than historically reported.

PMID 18563615  Int Urol Nephrol. 2009;41(1):77-83. doi: 10.1007/s11255・・・
著者: Xin-ru Zhang, Bao-jun Gu, Yue-min Xu, Rong Chen, Jiong Zhang, Yong Qiao
雑誌名: Chin Med J (Engl). 2008 Jun 5;121(11):1052-4.
Abstract/Text
PMID 18706259  Chin Med J (Engl). 2008 Jun 5;121(11):1052-4.
著者: Seiji Furuya, Haruaki Kato
雑誌名: J Urol. 2005 Sep;174(3):1039-42. doi: 10.1097/01.ju.0000169494.48968.aa.
Abstract/Text PURPOSE: We investigated the mechanism of hemospermia in patients with a midline cyst (MLC) of the prostate, focusing on cystic dilatation of the utricle (CDU) as a possible causative lesion.
MATERIALS AND METHODS: Of 138 patients with hemospermia 30 (22%) had an MLC, of whom 19 underwent transperineal needle aspiration of the MLC and bilateral seminal vesicles to determine the site of bleeding. Following MLC aspiration a mixture of dye and contrast medium was injected. The verumontanum was observed endoscopically and pelvic x-ray was done.
RESULTS: Seminal vesicle fluid on 1 or 2 sides was hemorrhagic in 13 of the 19 patients (aspiration failed in 6) and fluid from the MLC was nonhemorrhagic in 5 of the 19 (aspiration failed in 7). The MLC communicated with the urethra (CDU) in 15 patients (79%) and with 1 or 2 ejaculatory ducts in 11 (58%). In 5 of 11 patients with communication with the ejaculatory duct hemospermia persisted for more than 1 year. Four of these patients were cured by transurethral unroofing of the CDU.
CONCLUSIONS: CDU is a significant underlying lesion for hemospermia. Communication with the ejaculatory ducts was frequent in patients with chronic hemospermia and transurethral unroofing was effective for eliminating hemospermia.

PMID 16094043  J Urol. 2005 Sep;174(3):1039-42. doi: 10.1097/01.ju.000・・・

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契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

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ご契約はこちらから