Breast, nipple discharge

Probability diagnosis

Pregnancy

Physiological

Intraduct papilloma

Lactation/lactation cysts

Mammary dysplasia

Serious disorders not to be missed

Infection:

• acute mastitis/discharging breast abscess

• areolar abscess (infected gland of Montgomery)

• tuberculosis abscess

Cancer:

• intraduct carcinoma

• invasive carcinoma

• Paget disease of nipple

Other:

• hyperprolactinaemia

Pitfalls (often missed)

Mammary duct ectasia

Drugs (e.g. chlorpromazine, metoclopramide, OCP, cimetidine, opiates, amphetamines, CCBs, tricyclic antidepressants, phenothiazine)

Rarities:

• mammary duct fistula

• mechanical stimulation

Masquerades checklist

Drugs (as above)

Endocrine: hyperprolactinaemia, hypothyroidism

Key history

Family history of breast disease and past history including previous breast lumps, pain or nipple discharge. Note association with pregnancy, postpartum and lactation. Investigate drug intake including OTC preparations and illicit drugs especially opioids.

Key examination

• Careful examination of the breast, particularly the nipples and ductal area

• Examine associated lymph node regions

Key investigations

Select from:

• pregnancy test

• swab of any purulent discharge

• cytology of discharge

• prolactin level

• excision biopsy of discharging duct area.

Discuss imaging (e.g. mammography, ultrasound, galactography) with consultant

Diagnostic tips

• If the discharge is bilateral then serious breast disease is unlikely—consider mammary dysplasia and pregnancy.

• Bloodstained discharge is caused by intraduct papilloma (commonest) and intraduct carcinoma.

• Green-grey discharge: consider mammary dysplasia and mammary duct ectasia.

• Yellow discharge: intraduct carcinoma (serous), mammary dysplasia and pus from a breast abscess.

• Milky-white discharge (galactorrhoea): lactation, lactation cysts, hyperprolactinaemia and drugs.

• Consider malignancy in women with a new breast discharge (>40 years) and bloody discharge.

• Nipple discharge in a male is always abnormal.