Editorial Commentary

Abstract

Hongwei Zhao, Junhang Luo, Daohu Wang, Jian Lu, Wanmei Zhong, Jinhuan Wei, Andwei Chen. The value of transrectal ultrasound in the diagnosis of hematospermia in a large cohort of patients. J Androl. 2012;33: 897–903. There is currently no standard practice for managing patients with hematospermia. Some clinicians use transrectal ultrasound (TRUS) as a standard procedure, others do not require any investigation or use TRUS only when hematospermia is resistant to medical treatment. A diagnostic flow chart (Szlauer and Jungwirth, 2008) should be used to rule out underlying diseases. TRUS should be the initial step only for selected patients. In the report of Zhao et al (2012), the absence of pathological findings at TRUS was confirmed by MRI in all cases (14/14, 100%); therefore, the negative predictive value of TRUS is 100%. If TRUS is negative, no further imaging is necessary. TRUS is sometimes requested by patients, although they should be made aware that the risk of finding benign abnomalities is high (91.8%) and the rate of false positives is high. TRUS is widely used as the first imaging method, yet the procedure has not been standardized. On the basis of Zhao's results, standardization of minimal ultrasound parameters has been proposed (see the Table). An updated classification of prostate cyst disorders based on US findings by Galosi et al (2009) provides a useful aid in reporting such disorders. Most TRUS findings were benign in 97% of cases. Overall malignant tumors are detected in men more than 40 years old in 3.4% of published cases (41/1201). Dilatation of seminal vesicles because of cysts or calcification, which could cause hematospermia as a result of rupture of mucosal blood vessels or mechanical trauma by intraductal calcification, was detected in 72.8% of cases by Zhao et al (2012). In conclusion, TRUS could help rule out most anatomical abnormalities (cysts) or malformations, with good diagnostic accuracy for cystic tumors or large solid masses. Therefore, TRUS can be considered the first imaging method in selected cases, and MRI can be the second line of imaging to evaluate neoplasms or congenital disorders. I personally suggest TRUS as a routine practice in all patients more than 40 years old, except for those who have evident signs or symptoms of acute infection. I encourage clinicians who do not currently require any imaging investigation in cases of hematospermia to change their practice, taking these observations into account.