Hematospermia
ICD-10 R36.1 is a billable code used to indicate a diagnosis of hematospermia.
Hematospermia, defined as the presence of blood in the semen, can be a concerning symptom for patients and may indicate underlying pathology. It can be associated with various conditions affecting the male reproductive system, including infections, inflammation, trauma, or neoplasms. Common causes include prostatitis, seminal vesiculitis, urethritis, and benign prostatic hyperplasia. In some cases, hematospermia may be idiopathic, with no identifiable cause. Patients may present with additional symptoms such as dysuria, pelvic pain, or ejaculatory pain, which can aid in diagnosis. Laboratory findings may include abnormal semen analysis, elevated prostate-specific antigen (PSA) levels, or signs of infection in urine cultures. A thorough clinical evaluation, including a detailed history and physical examination, is essential to determine the underlying cause and guide appropriate management.
Detailed patient history, including duration and severity of symptoms, and any associated findings.
Patients presenting with hematospermia alongside urinary symptoms or pelvic pain.
Consideration of systemic diseases that may contribute to hematospermia.
Acute care documentation including vital signs, immediate interventions, and any imaging or lab results.
Acute presentations of hematospermia with severe pain or trauma.
Rapid assessment for potential life-threatening conditions.
When a biopsy is performed to rule out malignancy in a patient with hematospermia.
Pathology report and clinical notes indicating the need for biopsy.
Urology specialists may perform these procedures more frequently.
Documentation should include a detailed history of the symptom, associated clinical findings, results of any diagnostic tests, and the clinical rationale for the diagnosis.
