Evaluation of patient with nipple discharge

evaluation of patients with nipple discharge

A detailed history combined with a careful physical examination usually helps in an accurate differential diagnosis.

History should address the following:

• colour of discharge
  • blood stained discharge is always abnormal and usually suggestive of serious underlying pathology
  • presence of galactorrhoea is likely to indicate an endocrinopathy
    
    
• unilateral or bilateral
  • bilateral discharge is usually caused by systemic conditions e.g. - physiological (such as lactational), endocrine (such as prolactinoma, hypothyroidism) or iatrogenic (such as medications)
  • unilateral discharge indicates a local cause e.g - ductal papilloma, breast cyst, or ductal carcinoma
    
    
• associated symptoms
  • palpable breast lump or new-onset nipple inversion - suspect breast malignancy
  • local or systemic signs of infection in nipple discharge may be caused by an abscess
  • weight gain or cold intolerance may indicate that the nipple discharge is secondary to hypothyroididsm
    
    
• medications
  • ask about the use of medications which might cause nipple discharge
    
    
• other patient factors
  • age of patient
    • in premenopausal women and girls – most likely to be physiological, lactational, medication related, or secondary to a ductal papilloma
    • perimenopausal and postmenopausal - more likely due to a papilloma, duct ectasia, or breast cancer
    • discharge in male patients is abnormal

Examination of patient:

• inspection
  • look for signs suggesting an underlying breast cancer e.g. - skin tethering or asymmetry of the breasts, peau d’orange
  • erythematous skin may be seen in mastitis or breast abscess and in rare cases can be due do inflammatory breast cancer (specially in the absence of other signs of sepsis)
  • weeping of the skin – seen in atopic eczema or contact dermatitis from detergents, cellulitis, Candida infections, and mastitis
    
    
• palpation
  • examine of all four quadrants of the breast, axillary tail, axillae and supraclavicular regions to identify any masses or lymphadenopathy
  • observe the central breast below the nipples specially to identify the cause for discharge
  • palpate around the areola circumferentially to see if the discharge can be expressed (1)

Reference:

• (1) Labib PL, Gallegos N, Hegarty D. Nipple discharge. BMJ. 2015;351:h3123.