Blood in His Semen — Free SCA Practice Case
Man with blood in his semen
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Materials for Candidate
Please review before starting the consultation
Full Name
Ryan Talbot
Age
28 years
Consultation Type
VideoAge
28
Situation
Video Consultation, booked to discuss a personal matter.
Reason for Encounter
"I've noticed blood in my semen. The sexual health clinic tested me for everything and it was all clear, and they said to see my GP if it kept happening."
Medical Records
- ●PMH: Migraine.
- ●Medications: Ibuprofen PRN (patient-purchased; used for migraine, and at times pre-emptively).
- ●Allergies: NKDA.
- ●Recent notes: Nil in general practice. Sexual-health clinic (3 weeks ago): full STI screen — gonorrhoea, chlamydia, syphilis, HIV — all negative; urine culture negative. Advised to see GP if symptoms persisted.
Patient Script
For the friend playing the patient role
Character Overview: You are Ryan, a 28-year-old software developer. Over the past month you have noticed bright red blood mixed with your semen on four occasions. You went to a sexual-health clinic, where a full STI screen and urine sample were all negative, and they told you to see your GP if it continued. You are embarrassed and frightened — you are convinced it could be cancer. You take ibuprofen for migraines and sometimes take it when you do not have a headache, to try to prevent one. You live with your girlfriend of three years and have no other partners. You do not smoke or drink. You and your partner plan to start a family soon, and you want to know whether this could affect your fertility. You are relieved by clear explanation, but you will not be reassured by vague dismissal.
Opening Sentence: "Hi Doctor. This is a bit awkward… I've noticed blood in my semen — four times over the last month or so. I went to the sexual health clinic and all the tests came back clear, and they said to come to you if it carried on. I'll be honest, I'm worried it's cancer."
History if Asked (Data Gathering Phase)
- ●The symptom: "Bright red blood mixed in with the semen. Four times in about a month."
- ●The clinic tests: "They did the full screen — gonorrhoea, chlamydia, syphilis, HIV — and a urine test. All negative. They said see the GP if it kept happening."
- ●The ibuprofen: "I take ibuprofen for my migraines. Sometimes I take it even when I haven't got one, to try to head it off."
- ●How he feels: "Physically fine. But I'm frightened, and honestly embarrassed talking about it."
- ●What he wants: "I want to know what's causing it — and whether it'll affect us having kids."
ICE — Ideas, Concerns, Expectations
The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.
- ●Ideas: Ryan has been told by a pharmacist to get an STI screen (done, negative) and now suspects cancer. "The pharmacist said get an STI check — that was clear, so now I'm thinking cancer."
- ●Concerns: His dominant concerns are cancer and the effect on fertility, as he and his partner want children. "I'm scared it's cancer. And I'm worried it'll stop us having children."
- ●Expectations: He wants the cause identified and to be properly checked, not brushed off. "I want to know what it is — and not just be told not to worry."
If Asked — Haematospermia Assessment and Red-Flag Screen
The patient answers these only when directly asked. If the candidate signposts sensitively first, he answers more openly.
- ●If asked about the number of episodes and whether it is persisting: "Four times over about a month. It's still happening."
- ●If asked about the colour (bright red vs brown/rust): "Bright red — fresh-looking, mixed through the semen." (Fresh bleeding rather than old.)
- ●If asked about pain on ejaculation: "No pain when I ejaculate."
- ●If asked about urinary symptoms (dysuria, frequency, urgency, nocturia, poor stream): "No, my waterworks are completely normal."
- ●If asked about blood in the urine: "No, I've never seen blood in my urine." (Important — its presence would change the pathway.)
- ●If asked about perineal, testicular, suprapubic, or lower back pain: "No pain anywhere down there."
- ●If asked about fever, chills, or feeling unwell (infection): "No fever, I feel well."
- ●If asked about weight loss or night sweats (malignancy red flags): "No weight loss, no night sweats."
- ●If asked about testicular lumps or swelling: "No lumps or swelling that I've felt."
- ●If asked about sexual history and STI screening: "One partner, together three years, no others. Full screen at the clinic — all negative."
- ●If asked about trauma, or vigorous cycling/horse riding (perineal trauma): "No injury. I don't cycle much."
- ●If asked about recent prostate procedures, catheterisation, or biopsy: "Nothing like that."
- ●If asked about NSAIDs, anticoagulants, or antiplatelets: "Just the ibuprofen — quite often, including when I've no headache."
- ●If asked about bleeding elsewhere (gums, nose, bruising) or a family bleeding history: "No, nothing like that."
- ●If asked about family history of prostate, testicular, or urological cancer: "None that I know of."
- ●If asked about blood pressure history: "I've never been told my blood pressure's high."
Responses to Management (The Negotiation Phase)
- ●If the Doctor explains haematospermia and the age-based rule: "So in someone my age, with clear tests and no other symptoms, it's usually harmless and settles by itself? That's not what I'd assumed." (The tested point is explaining the age-based rule and the benign natural history — reassurance grounded in reasoning.)
- ●If the Doctor explains why extensive tests are not needed: "So I don't need scans or a load of tests? Part of me wants everything checked, to be honest." (The tested point is explaining why investigation is not required, persuasively enough that he is genuinely reassured rather than feeling fobbed off.)
- ●If the Doctor raises the ibuprofen as a possible contributor: "The ibuprofen could be part of it? I hadn't thought of that — I do take a lot of it, and often for no reason." (The tested point is identifying and addressing NSAID use as a contributing factor.)
- ●If the Doctor arranges a face-to-face examination: "You need to examine me properly rather than over video? Yes, that's fine." (The tested point is arranging appropriate in-person examination, with a chaperone offered.)
- ●If the Doctor answers the fertility question: "So it shouldn't affect our chances of having children? That's the biggest relief of all." (The tested point is answering his specific fertility question directly.)
- ●If the Doctor safety-nets: "What would mean I need to come back or be referred?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Haematospermia — Usually Benign in Younger Men
- ●Haematospermia (blood in the semen) is alarming to patients but is usually benign and self-limiting, particularly in men under 40 with no red flags. Common causes include inflammation/infection of the prostate or seminal tract, minor trauma, instrumentation, and a contribution from NSAIDs or a bleeding tendency.
The Age-Based Rule
- ●In men under 40 with a single or short-lived episode, no haematuria, no red flags, and negative infection screening, reassurance and observation are appropriate — investigation is often not required.
- ●Age 40 or over, persistent or recurrent symptoms, or any red flag warrant investigation and urological referral (prostate assessment including PSA/DRE as appropriate, and imaging).
The Pathway-Changing Questions
- ●Always ask about visible haematuria (which shifts assessment towards urinary tract investigation), pain on ejaculation and urinary symptoms (prostatitis/urethritis), systemic red flags (weight loss, night sweats, fever), and testicular abnormality.
Contributing Factors
- ●Review NSAIDs, anticoagulants, and antiplatelets, screen for a bleeding disorder (bleeding at other sites, family history), and ask about trauma, vigorous cycling/horse riding, and recent prostate procedures. Consider infection/STI — and note that a negative screen is useful evidence.
Proportionate Assessment
- ●Arrange limited, proportionate assessment: urine dipstick and culture, blood pressure, and face-to-face examination (genitalia/testes, abdomen, prostate where indicated, chaperone offered) — a genital examination cannot be performed by video.
Reassurance Without Dismissal
- ●Effective reassurance is explained: name the condition, give the likely causes, set out the expected natural history, and specify exactly when to return. Bland reassurance ("nothing to worry about") leaves an anxious patient dissatisfied and is a common failure.
Answer the Question the Patient Actually Asked
- ●Address specific concerns directly — here, that haematospermia itself would not be expected to affect fertility — and the cancer fear explicitly. Arrange follow-up to confirm resolution.
Common Candidate Mistakes in This Case
- ●Over-investigating or over-referring: applying an older man's pathway to a 28-year-old with a benign picture.
- ●Bland reassurance: telling him not to worry without explanation, so he feels dismissed and stays frightened.
- ●Not asking about haematuria: missing the question that would change the pathway.
- ●Missing the NSAID contribution: overlooking frequent, partly unnecessary ibuprofen use.
- ●Managing on video / ignoring the fertility question: failing to arrange an in-person examination, or leaving his fertility concern unanswered.