Haematospermia - Investigation/Management for primary care and appropriate referral for secondary care 
Greater Glasgow and Clyde
Hematospermia is the presence of grossly bloody or blood-tinged penile (seminal) ejaculate, is an uncommon condition. While it is usually alarming to patients, the cause is almost always benign. Only a few case series have been published, nearly all of which are from urology specialty practices.
Because of the paucity of research literature, there is little evidence on which clinicians can base their evaluation of patients with hematospermia. Searching for the rare causes that have been identified in case reports is not likely to be productive and the relative frequencies of causes reported in case series from urology specialty practices may not apply to primary care practice. The most important lesson from the literature is that hematospermia is almost never a sign of cancer in younger patients.
The most common cause of hematospermia is prostate biopsy. Hematospermia occurs in more than 80 percent of men undergoing prostate biopsy and lasts for an average of three to four weeks Vasectomy can also cause hematospermia for a week or more. 
A variety of conditions other than prostate biopsy have been reported in patients with hematospermia. They include benign and malignant disorders of the prostate gland, seminal vesicles, spermatic cord, and ejaculatory duct system; urogenital infections including sexually transmitted infections (eg, chlamydia, herpes simplex virus, gonorrhea, trichomonas); metastatic cancers; vascular malformations; congenital and drug-induced bleeding disorders; and even frequent daily ejaculation over a period of several weeks. However, it is often impossible to know with certainty whether these conditions are the cause of hematospermia. 
The cause is idiopathic in a substantial proportion of patients, and the condition frequently resolves spontaneously.

Primary care
Men under the age of 40 years with 3 or less episodes of haematospermia do not require referral. The condition is normally self-limiting. 
For men over 40 years of age or persistent haematospermia in the under 40 year age group
General Practitioners should 
Examine:
Blood pressure for uncontrolled hypertension.
For signs of anaemia and bruising associated with an acquired bleeding disorder.
The penis and the urethral meatus for signs of genital warts, or unreported injury.
The testes for signs of cancer. 
The prostate for signs of benign prostatic hyperplasia or cancer.
The abdomen for abnormalities of the kidneys, liver, or spleen that could indicate an acquired bleeding disorder.
Send a mid-stream urine sample for analysis and culture in all men and boys. ( Semen culture is not required )
Consider other investigations guided by clinical findings:
Investigations for a sexually transmitted infection (in men with symptoms or who are at risk).
A full blood count, coagulation screen, and renal and liver function tests.
Prostate specific antigen (PSA) level if prostate cancer is suspected.
Scrotal ultrasound if there is testicular swelling.

Referral to secondary care
Should be reserved for men over 40 years of age with either an abnormal digital rectal examination and or elevated PSA, 
Abnormal scrotal USS 
Urinary tract infection/prostatitis