Accepted Manuscript

Title: Tertiary Referral Hospital Experiences of Men Presenting with Painless

Post-Coital Gross Hematuria and a Suggestion for the Management Algorithm

Author: Dong Hyuk Kang, Joo Yong Lee, Dae Chul Jung, Young Taik Oh,
Eun Suk Cho, Sung Yoon Park, Ki Soo Lee, Kang Su Cho

PII: S0090-4295(18)30103-1
DOI: https://doi.org/10.1016/j.urology.2018.01.041
Reference: URL 20888

To appear in: Urology

Received date: 9-11-2017

Accepted date: 31-1-2018

Please cite this article as: Dong Hyuk Kang, Joo Yong Lee, Dae Chul Jung, Young Taik Oh, Eun
Suk Cho, Sung Yoon Park, Ki Soo Lee, Kang Su Cho, Tertiary Referral Hospital Experiences of
Men Presenting with Painless Post-Coital Gross Hematuria and a Suggestion for the Management
Algorithm, Urology (2018), https://doi.org/10.1016/j.urology.2018.01.041.

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 Tertiary referral hospital experiences of men presenting with painless post-coital gross hematuria and a

suggestion for the management algorithm Comment [A1]: AUTHOR: Please check if
the article title used is correct.

Dong Hyuk Kang1, Joo Yong Lee2, Dae Chul Jung3, Young Taik Oh3,

Eun Suk Cho4, Sung Yoon Park3, Ki Soo Lee5, and Kang Su Cho6

1
Department of Urology, Inha University School of Medicine, Incheon, Korea
2
Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of

Medicine, Seoul, Korea

3
Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei College of

Medicine, Seoul, Korea

4
Department of Radiology, Gangnam Severance Hospital, Yonsei College of Medicine, Seoul, Korea

5
Department of Urology, Donga University College of Medicine, Busan, Korea
6
Department of Urology, Gangnam Severance Hospital, Urological Science Institute, Yonsei University College

of Medicine, Seoul, Korea

Running head: Experiences of men presenting with painless post-coital gross hematuria

Manuscript word count: 2782 / Abstract word count: 233

Key words: Hematuria; Arteriovenous Malformation; Coitus; Ejaculation; Erection

Corresponding author:

Kang Su Cho, M.D., Ph.D.

Department of Urology, Gangnam Severance Hospital, Urological Science Institute, Yonsei University

Page 1 of 21
 College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 135-720, Korea

Tel.: +82-02-2228-2320 / Fax: + 82-2-3462-8887 / E-mail: kscho99@yuhs.ac

Abstract

Objective: To review the tertiary referral hospital experiences of men presenting with painless post-coital gross

hematuria (PCGH) and suggest the management algorithm.

Materials and Methods: We reviewed clinical data from 19 male patients who first visited a clinic because of

PCGH between 2009 and 2016. The patients were evaluated according to our tentative management algorithm

for painless PCGH. First, a general work-up for painless gross hematuria (GH) was performed. If the cause of

the PCGH was not identified, a vascular work-up of the pelvic vasculatures for PCGH was performed, including

transrectal and penile ultrasonography (USG) with Doppler study. Pelvic angiography and subsequent

angioembolization were recommended at the physician’s discretion.

Results: The median age of the patients was 47 (range: 30–67) years. The tentative management algorithm led

to no abnormal findings in seven patients and identified urological malignancies in two patients.

Urethrocystoscopy revealed urethral hemangioma in three patients. Doppler USG revealed pelvic varicosities in

three patients, complicated cyst of Cowper's glands in one patient, and pelvic arteriovenous malformation in

three patients. Pelvic angiography was recommended for the three patients with pelvic arteriovenous

malformation, and two of those patients were successfully treated by angioembolization.

Conclusions: The clinical approach to painless PCGH should be different than that to painless GH. Both the

general and the vascular work-up for the pelvic vasculatures for painless GH are mandatory for the evaluation of

patients with painless PCGH.

Introduction

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 Hematuria, either macroscopic or microscopic, is one of the main reasons for which patients seek

urologic and nephrologic consultation. Gross hematuria (GH) can be regarded as an important initial symptom

or sign of various urologic diseases, such as urologic malignancies, urinary stones, or urinary tract infection. 1

Careful attention should be paid to GH because of its potential association with urologic malignancies such as

bladder cancer. Therefore, a complete evaluation including cystoscopy, urine cytology, and computed

tomography (CT) scan, is recommended.2

Intercourse-related microscopic hematuria can occur in some cases and minor trauma to the urethra

and bladder is a possible explanation for such presentation. 3-5 But, post-coital gross hematuria (PCGH) is

encountered very infrequently in urologic clinics. There have been only a few reports dealing with a small

number of case experiences. Although PCGH might occur regardless of sex, all previously reported cases

involved male patients.6-16 A variety of etiologies have been raised as a cause of PCGH, including urethral

hemangioma, adenoma of the prostatic urethra, benign prostatic hyperplasia (BPH), pelvic arteriovenous

malformation (AVM), and urethral injury.6-15 Amano et al. advocated that conservative management and careful

observation are sufficient for men with PCGH because of the absence of serious and/or malignant disease in

their experience with 15 cases.16

Nevertheless, painless PCGH seems to be distinct from painless GH. Its clinical significance is still

unclear, however, and there is lack of standardization in the diagnosis of and treatment for painless PCGH.

Taken together, these symptoms may be related to general GH-causing diseases, but may also be related to

vascular problems, considering the hemodynamic changes that occur during erection and ejaculation.

Sometimes it disappears naturally without special treatment; however, in some cases the symptoms persist, and

proper treatment may be necessary to improve symptoms. We believe it would be very valuable for andrologists

to explore the etiology and natural history of PCGH that have not yet been elucidated, in addition to studying

appropriate diagnosis and treatment. Herein, we report the tertiary referral hospital experiences of men with

painless PCGH and present a management algorithm that incorporates our experience with previously reported

cases of PCGH.

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 Materials and Methods

We reviewed medical records of first-visit men presenting painless PCGH between 2009 and 2016 at

our outpatient clinics. We thus identified a total of 19 patients and retrospectively collected data from those

cases. We performed the study in accordance with applicable laws and regulations, good clinical practices, and

ethical principles as described in the Declaration of Helsinki. The institutional review board at Severance

Hospital approved the study (Approval Number: 4-2016-0227).

We presented and analyzed the data concerning the clinical diagnosis, treatment, and prognosis of the

identified patients. When the patients first visited the clinic, past history including medication was obtained. The

duration and frequency of PCGH, its provocative events, and the presence of concomitant hemospermia were

determined. Further evaluations were then performed according to our management algorithm for painless

PCGH (Fig. 1). First, a general work-up for painless GH was performed, which included laboratory tests,

abdomen-pelvis CT, and urethrocystoscopy. If a cause for the PCGH was not identified, a vascular work-up for

PCGH was carried out as follows. Transrectal and penile USG with Doppler study were performed to evaluate

the prostate, penis, and relevant vasculatures. In cases where the Doppler study suggested vascular abnormalities,

diagnostic pelvic angiography and subsequent angioembolization were recommended at the physician’s

discretion.

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 Results

1. Past history

The median age of the patients was 47 (range: 30–67) years. No relevant past history was found for

any of the patients. None of the patients were taking anticoagulants or had coagulopathy. All of the patients

complained of GH after ejaculation. Four (21.1%) of the patients further reported GH even after erection

without ejaculation. Three patients (15.8%) experienced concomitant hemospermia (Table 1).

2. General work-up for painless GH

Urinary tract infection was not detected in any of the patients, and all of the patients had negative

urine cytology. Urethrocystoscopy was performed in all of the patients, indicating urethral mucosal bulging in

three patients (15.8%) and papillary bladder mass in one patient (5.3%). Fig. 2A shows typical mucosal bulging

suggestive of hemangioma, but pathological confirmation was not performed. All of the patients underwent

abdomen-pelvis CT scan, which revealed engorged periprostatic vasculature in one patient (5.3%), probable

cystitis with the enhancement of bladder mucosa in one patient (5.3%), and right renal mass in one patient (5.3%;

Table 1). PSA testing was conducted in 14 patients, all of which presented results in the normal range.

3. Vascular work-up for PCGH: USG with Doppler study and angiography

Transrectal and penile USG with Doppler study were performed in 17 patients, excluding the two

patients with malignancies. One patient (5.3%) showed a 0.7 cm tear drop-shaped cystic lesion in the left-side

urogenital diaphragm. That finding was suspicious for a complicated cyst of the Cowper's glands. Abnormal

pelvic vasculature was observed in six patients (31.6%). The location of those lesions was in the periprostatic

area in four patients and in the penile root area in two patients. Three (15.8%) of the patients with abnormal

pelvic vasculature had vascular dilatation without apparent arterial flow suspicious of venous varicosity. In the

other three patients with abnormal pelvic vasculature, Doppler USG showed that the inflow of blood shunted
5

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directly to the outflow of blood, suggesting AVM (Fig. 2B and 2C). Pelvic angiography was recommended to

those three patients for confirmatory diagnosis. One patient refused angiography evaluation because of the

potential risk of erectile dysfunction after angioembolization, but the other two patients underwent angiography,

which revealed AVM lesions arising from one of the internal pudendal artery branches (Fig. 2D and 2E). Those

two patients were subsequently managed by angioembolization (Fig. 2F).

Finally, seven patients (36.8%) showed non-specific findings after undergoing our management

algorithm for painless PCGH. Potentially causative lesions were identified in the other 12 patients (63.2%), and

confirmatory or presumptive diagnosis was made as follows: urologic malignancies in two patients (10.5%),

urethral hemangioma in three patients (15.8%), complicated cyst in the urogenital diaphragm in one patient

(5.3%), pelvic varicosity in three patients (15.8%), and pelvic AVM in three patients (15.8%; Table 2).

4. Follow-up

In the seven patients that revealed no causative lesions, the PCGH disappeared during follow-up. Of

the three patients with AVM, the two that received angioembolization were symptom free at the last follow-up

visit, whereas the one that refused angiography was still suffering from intermittent PCGH at the last follow-up

visit. Of the three patients that had pelvic varicosity without evidence of AVM, two showed improvement of

symptoms at the last follow-up visit, but the other showed continuing symptoms at the last follow-up visit. In

the three patients with urethral hemangioma-like lesions, the symptoms disappeared without any specific

intervention. The two patients with malignancies underwent proper management for bladder and kidney cancer,

respectively (Table 2).

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 Discussion

PCGH is a very rare urologic symptom, causing embarrassment and leading patients to seek medical

consultation. To the best of our knowledge, there are only 32 previously reported cases of PCGH. Most of the

previous studies of PCGH included limited experiences with small numbers of cases. All of the previous studies

of PCGH are summarized in supplementary Table 1. It is not uncommon to fail to specify an obvious cause of

PCGH in real clinical settings, but a variety of lesions have been demonstrated as causal lesions in the literature.

In 1985, Aliabadi et al. reported a 29-year-old man experiencing PCGH for the first time, which was

caused by a benign prostatic utricular papilloma. 6 That same year, Redman et al. reported a 29-year-old man

with PCGH caused by large varicosities at the apex of the prostate.13 Both of those cases were treated

successfully by endoscopic resection and fulguration, respectively. Two cases of posterior urethral adenoma and

one case of urethral erythematous plaque-like lesion have also been reported.11,12 Those patients were treated

with transurethral resection with fulguration using a holmium:YAG laser. BPH was one of the causes of PCGH

in those cases. Chen et al. performed urethrocystoscopy on a 61-year-old man and detected multiple active

bleeders at the prostate.7 They tried to treat the patient with fulguration but failed; however, they subsequently

resolved the PCGH with dutasteride medication. Urethral injury was reported in one case of PCGH,8 which was

successfully treated with fulguration. In 1996, Hong et al. reported a 53-year-old man with pelvic AVM that was

diagnosed by internal iliac arteriography and treated with embolization. 10 Tsui et al. reported a similar case in

which they confirmed left pudendal and obturator arterial bleeding by angiography and subsequently performed

embolization.15 During the last decade, several studies of PCGH have described a number of cases.

Gkougkousis et al. reported three cases of urethral venous malformation, which they treated with

electrocoagulation of the abnormal veins.9 Saito tracked the symptoms of 20 patients diagnosed with urethral

hemangioma, five (25%) of which complained of initial hematuria and/or urethral bleeding after erection. Those

patients were treated with resection.14 The most recent study is that by Amano et al., which included 15 patients

with PCGH.16 Three of those patients were diagnosed with BPH, and one was diagnosed with cystic lesion of

the prostate.

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 Indeed, there has so far been no standardization of the diagnosis and treatment of patients with

painless PCGH. Most physicians have managed such patients in the same manner in which they manage patients

with painless GH in general. PCGH is not simply the same as painless GH but is instead erection-associated

and/or ejaculation-associated GH. Therefore, it is not reasonable to manage painless PCGH with the same

strategy that is used for painless GH. Erection is a physiologic phenomenon accompanied by vigorous

hemodynamic change of the male pelvis. Accordingly, pelvic vasculatures and erection-related vascular events

should be evaluated by USG with Doppler study or angiography. For those reasons, we have developed the

management algorithm for painless PCGH based on the previously reported literature. This algorithm consists

of two steps: a general work-up for painless GH and a vascular work-up for PCGH.

We reported the 19 patients with PCGH that were evaluated according to our management algorithm.

Probable causative lesions were found in five patients (26.3%) through the general work-up for painless GH and

in seven patients (36.8%) through the vascular work-up for PCGH, but no causative lesions were identified in

seven patients (36.8%). The first step in our algorithm is the general work-up for painless GH, including

laboratory tests, CT, and urethrocystoscopy, which can identify urologic malignancy, urolithiasis, and other

anatomical abnormalities. Although previous reports showed no urologic malignancies associated with painless

PCGH, it is important to confirm or exclude the presence of urologic malignancy, because such malignancy is

critically associated with the health of the patients. In our study, the general work-up for painless GH revealed

urologic malignancies in two patients. On the other hand, PCGH might be caused by elevated blood pressure

during sexual intercourse, which affects engorged vessels on the prostatic urethra and other vulnerable

vasculatures within hemangiomas and urethral polyps. Therefore, physicians should keep their attention on the

urethra during urethrocystoscopy, paying special attention to the posterior urethra.

The second step in our algorithm is the vascular work-up for PCGH, including transrectal and penile

USG with Doppler study and pelvic angiography. This specific work-up for pelvic vasculature must be

performed after the completion of general work-up for GH. Careful investigation of the pelvic vasculature may

reveal pelvic varicosity and AVM in patients with PCGH. AVM is widely known because of its occurrence in the

central nervous system, but it can appear in any location. Although many AVMs are asymptomatic, they can

cause intense bleeding.17,18 In the flaccid penis, the smooth muscles of the cavernous arterioles and trabeculae

are contracted, and minimal blood flow enters the sinusoids. Relaxation of those smooth muscles incites arterial
8

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dilation, venous compression, and sinusoidal relaxation, resulting in penile erection.19 Likewise, massive arterial

inflow into the pelvis can damage pelvic AVMs during sexual intercourse, and PCGH can subsequently occur.

The etiology of pelvic AVM is uncertain in most cases, but pelvic trauma can be a cause, so a history of pelvic

trauma should be taken.20 When conducting USG for vascular evaluation, Doppler study is mandatory, and full-

erection status is more appropriate for checking the vascular malformation. Once a suspicious lesion of pelvic

AVM is noted on Doppler study, pelvic angiography should be considered. If pelvic AVM is confirmed by

diagnostic angiography, concurrent embolization could be attempted. Angioembolization may induce

diminished erection, however, and most patients are sexually active, so written consent with detailed counseling

is needed prior to the procedure.

There were several cases of pelvic vascular malformation in the previously reported PCGH patients.

In addition, in our study, six of 17 patients (35.3%) had abnormal findings in pelvic vasculature. As this is

considered not a small proportion, the authors of this study believe penile and transrectal Doppler USG is an

essential test to be performed at a later stage in general work-up for GH. Also, three of these six patients were

suspected of AVM, and two patients who agreed to angiography received an examination as well as AVM

diagnosis and treatment simultaneously. However, the effectiveness of penile and transrectal USG can be

debatable, due to the frequent symptomatic improvement of PCGH without any treatment. Additional studies

and cases should be clarified for application of more reliable algorithms in the future. Also, since penile and

transrectal Doppler USG should be performed by a radiology specialist who is both experienced and highly

skilled, it should only be conducted at advanced medical institutions that are equipped with such personnel to

reduce false positive rate and avoid unnecessary pelvic angiography.

In our study and in the previous literature, various etiologies for PCGH have been shown, and cause-

specific treatment modalities have been introduced. Currently, angioembolization is regarded as the treatment of

choice for patients with pelvic AVM. In our study, two cases of PCGH were successfully treated with

angioembolization for pelvic AVM, which is comparable to previously reported cases.10,15 There is controversy,

however, regarding the treatment of PCGH caused by other etiologies. Most of the previously reported cases

were treated surgically, but that trend might be affected by publication bias. For example, several reports

demonstrated that large varicosity, urethral adenoma, and hemangioma could be successfully treated by

transurethral resection or fulguration.9,11-14 Nevertheless, we did not offer any treatment for patients with
9

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hemangioma-like lesions revealed by urethrocystoscopy nor for those with pelvic varicosity revealed by USG,

and the symptoms of most of those patients improved during follow-up. We believe that immediate surgical

management is not necessary for such patients, and surgery should be limited to the patients who show

persistent or recurrent symptoms. In one patient, USG revealed a cystic lesion on the urogenital diaphragm,

which was suggestive of a complicated cyst in the Cowper's glands.21 That patient was also followed up without

any specific treatment.

We reported on 19 cases PCGH to which we applied our management algorithm. To the best of our

knowledge, this is the largest case series for PCGH. Although the number of cases is not sufficient to obtain

concrete conclusions, meaningful lessons can be drawn from our experiences. First, it is noteworthy that the

vascular work-up resulted in abnormal findings in one third of the patients, indicating that the vascular work-up

is mandatory rather than optional for the evaluation. Second, clinicians should not overlook the possibility of

urologic malignancy. The previous literature did not show any cases with urologic malignancy, but our study

revealed two such cases. That difference might be explained by publication bias; there may be no need for

publication if a patient with PCGH is revealed to have urological cancer, because during sexual intercourse,

increased abdominal pressure and massive arterial inflow into the pelvis may affect cancer bleeding, resulting in

the PCGH. Third, in the cases in which our algorithm found no discernible lesion, the PCGH improved without

sequelae during follow-up, although no specific treatment was given. Overall, we believe that this algorithm is

feasible for use in common clinical practice, and that it can be also used for clinical research. Our study has

some inherent limitations, however, due to its retrospective design and small number of cases. More clinical

experiences should be accumulated to obtain a more thorough understanding of the pathophysiology of painless

PCGH. Well-designed clinical studies are needed to establish the best strategy for patients with painless PCGH.

10

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 Conclusions

The clinical approach to painless PCGH should be different than that to painless GH. The general

work-up for painless GH and the vascular work-up for PCGH are both mandatory for the evaluation of patients

with painless PCGH. Our management algorithm seems to be feasible and reasonable. More clinical experiences

should be accumulated to establish the best strategy for patients with painless PCGH.

References

1. Higgins CC: The clinical significance of hematuria. J Am Med Assoc 1958; 166: 203.

2. Wein AJ, Kavoussi LR, Novick AC et al: Campbell-Walsh Urology, 10th Edition: Elsevier Health

Sciences 2011

3. Harris NM, Yardley I, Basketter V et al: Is sexual intercourse a significant cause of haematuria? BJU

Int 2002; 89: 344.

4. Hosseini SR, Mohseni MG, Atharikia D: Role of sexual intercourse in hematuria and proteinuria in

males and females. Urol Int 2008; 81: 271.

5. Mazouz B, Almagor M: False-positive microhematuria in dipsticks urinalysis caused by the presence of

semen in urine. Clin Biochem 2003; 36: 229.

6. Aliabadi H, Cass AS, Gleich P: Utricular papilloma. Urology 1987; 29: 317.

7. Chen YH, Lin PY, Cheng YS et al: Post-coital gross hematuria: an unusual presentation of benign

prostatic hyperplasia. Asian J Androl 2007; 9: 856.

8. Cheng YS, Lin JS, Lin YM: Isolated posterior urethral injury: an unusual complication and presentation

following male coital trauma. Asian J Androl 2006; 8: 379.

9. Gkougkousis EG, Khan M, Terry TR et al: Urethral venous malformation: an unusual cause of

recurrent post-coital gross haematuria in association with haematospermia. Ann R Coll Surg Engl 2009;

91: 532.
11

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10. Hong SJ, Park DW, Kim MJ et al: Transrectal color Doppler ultrasonography for postejaculation

hematuria. Abdom Imaging 1996; 21: 551.

11. Kumar R, Kesarwani P, Shrivastava DN et al: Post coital hematuria: presentation of an uncommon case.

J Postgrad Med 2004; 50: 312.

12. Mi ZG, Yang XF, Liang XZ et al: Adenoma of the posterior urethra: 131 case report. Asian J Androl

2001; 3: 67.

13. Redman JF, Young JW, 3rd: Massive post-ejaculation hematuria. Urology 1987; 30: 73.

14. Saito S: Posterior urethral hemangioma: one of the unknown causes of hematuria and/or

hematospermia. Urology 2008; 71: 168 e11.

15. Tsui KH, Wang LJ, Chang PL et al: Hematuria from left internal pudendal and obturator arterial

bleeding following sexual intercourse. Arch Androl 2003; 49: 453.

16. Amano T, Otani T, Ryuge Y et al: Male post-coital gross hematuria: are there any complications?

Journal of Men's Health 2011; 8: 136.

17. Fults D, Kelly DL, Jr.: Natural history of arteriovenous malformations of the brain: a clinical study.

Neurosurgery 1984; 15: 658.

18. Graf CJ, Perret GE, Torner JC: Bleeding from cerebral arteriovenous malformations as part of their

natural history. J Neurosurg 1983; 58: 331.

19. Aboseif SR, Lue TF: Hemodynamics of penile erection. Urol Clin North Am 1988; 15: 1.

20. Papadakos N, Wales L, Hayes K et al: Post-traumatic pelvic pseudoaneurysm and arterio-venous fistula:

combined endovascular and surgical approach. Eur J Vasc Endovasc Surg 2008; 36: 164.

21. Selli C, Nesi G, Pellegrini G et al: Cowper's gland duct cyst in an adult male. Radiological and clinical

aspects. Scand J Urol Nephrol 1997; 31: 313.

12

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 Figure Legends

Figure 1. The management algorithm for patients with painless PCGH

CT, computed tomography; PCGH, post-coital gross hematuria; PSA, prostate-specific antigen; USG,

ultrasonography

Figure 2. (A) Urethrocystoscopic appearance of a patient (case 7) with mucosal bulging below the

verumontanum (arrow). (B) Transrectal ultrasonography with Doppler study of a patient (case 13) showing

increased arterial flow and marked dilatation of adjacent veins (arrow). (C) Penile ultrasonography with Doppler

study of a patient (case 4) showing prominent vascularity with inflow of blood shunted directly to the outflow of

blood on bulbous spongiosum (arrow). (D) and (E) Pelvic angiography of a patient (case 4) showing abnormal

staining of a bulbocavernosal artery (arrows). (F) Angioembolization was performed by Gelfoam® after

protection of the distal part using Tornado® coils (arrow).

13

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Table 1. Clinical features and summary of general work-up for painless gross hematuria in 19 patients with PCGH
Cas Age Duratio Frequency Past Events Hemospermi Urine PSA Urethrocystoscop Abdomen-
e (years n histor preceding a cytolog (ng/mL y pelvis CT
) y PCGH y )
1 36 7 years Intermitten (-) Ejaculatio (-) ND ND (-) Engorged
t n only paraprostat
e
vasculature
2 48 15 Intermitten (-) Both (-) (-) 0.6 Mucosal bulging (-)
years t ejaculation of bulbous urethra
and
erection
3 45 4 Every time (-) Ejaculatio (-) (-) 0.25 (-) (-)
months n only
4 44 8 years Intermitten HCV Both (-) (-) 0.45 (-) (-)
t carrier ejaculation
and
erection
5 46 4 years Intermitten (-) Ejaculatio (-) (-) 0.62 Mucosal bulging (-)
t n only below
verumontanum
6 57 8 Every time DM Ejaculatio (-) (-) 0.9 (-) (-)
months n only
7 31 1 week Every time (-) Ejaculatio (-) (-) ND Mucosal bulging (-)
n only below
verumontanum
8 58 2 years Intermitten (-) Ejaculatio (-) (-) 0.82 (-) (-)
t n only
14

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 9 59 3 years Intermitten HTN Ejaculatio (-) (-) 0.31 (-) (-)
t n only
10 47 1 year Intermitten LC Both (-) (-) 0.67 (-) (-)
t ejaculation
and
erection
11 65 2 Intermitten (-) Ejaculatio (-) (-) 1.36 (-) (-)
months t n only
12 61 4 Intermitten (-) Both (+) (-) 0.6 (-) (-)
months t ejaculation
and
erection
13 67 4 years Intermitten (-) Ejaculatio (-) (-) 0.73 (-) (-)
t n only
14 51 1 week Once (-) Ejaculatio (-) (-) 0.99 Bloody efflux at Right renal
n only right ureteral mass with
orifice metastasis
15 43 2 Twice DM Ejaculatio (-) (-) ND Papillary bladder Probable
months n only mass cystitis
16 38 1 year Intermitten (-) Ejaculatio (-) (-) ND (-) (-)
t n only
17 65 6 Intermitten (-) Ejaculatio (-) (-) 1.95 (-) (-)
months t n only
18 40 3 years Intermitten (-) Ejaculatio (+) (-) 0.71 (-) (-)
t n only
19 30 3 Intermitten (-) Ejaculatio (-) (-) ND (-) (-)
months t n only
CT, computed tomography; DM, diabetes mellitus; HCV, hepatitis C virus; HTN, hypertension; LC, liver cirrhosis; ND, not done;
15

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PCGH, post-coital gross hematuria

16

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Table 2. Clinical features and summary of vascular work-up for painless PCGH in 19 patients with PCGH

Case TPV (mL) Prostate & penile USG with Doppler Pelvic Diagnosis Treatment Symptom at
study angiography last follow-
up
1 23.3 Prominent vascularity with inflow of blood AVM AVM Embolization Improved
shunted directly to the outflow of blood
on right-side periprostatic area
2 18 (-) ND Urethral hemangioma Observation Improved
3 25 Prominent vascularity on right-side ND Pelvic varicosity Observation Improved
periprostatic area without apparent
arterial flow
4 17 Prominent vascularity with inflow of blood AVM AVM Embolization Improved
shunted directly to the outflow of blood
on bulbous spongiosum
5 19 (-) ND Urethral hemangioma Observation Improved
6 25.8 Prominent vascularity on penile root area ND Pelvic varicosity Observation Improved
without apparent arterial flow
7 20 (-) ND Urethral hemangioma Observation Improved
8 23.2 (-) ND (-) Observation Improved
9 20.2 (-) ND (-) Observation Improved
10 17.3 (-) ND (-) Observation Improved
11 39.5 (-) ND (-) Observation Improved
12 29 Prominent vascularity on right-side ND Pelvic varicosity Observation Persistent
periprostatic area without apparent
arterial flow
17

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 13 19.3 Prominent vascularity with inflow of blood ND AVM Angiography Persistent
shunted directly to the outflow of blood recommended
on left-side periprostatic area
14 ND ND ND RCC T3N+M+ Cancer Improved
treatment
15 ND ND ND Bladder tumor Cancer Improved
treatment
16 17.5 (-) ND (-) Observation Improved
17 35.3 (-) ND (-) Observation Improved
18 21.1 (-) ND (-) Observation Improved
19 26.0 0.7 cm sized tear drop-shaped cystic ND Complicated cyst in Observation Improved
lesion in left-side urogenital diaphragm Cowper's glands
AVM, arteriovenous malformation; ND, not done; PCGH, Post-coital gross hematuria; RCC, renal cell carcinoma; USG,
ultrasonography

18

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19

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Figure 1.jpg

20

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Figure 2.jpg

21

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