Diseases » Gynecomastia » Diagnosis

Diagnosis of Gynecomastia

Gynecomastia Diagnosis: Book Excerpts

• Ask the Following Questions - GYNECOMASTIA
• Ask the following questions - BREAST DISCHARGE
• Differential Diagnosis - Breast Pain & Discharge
• Differential Diagnosis - Gynecomastia
• Differential Diagnosis - Enlarged Anterior Fontanelle
• Approach to the Diagnosis - GYNECOMASTIA
• Approach to the Diagnosis - BREAST DISCHARGE
• History and physical examination - Gynecomastia
• History and physical examination - Breast nodule [Breast lump]
• Diagnosis - Mastitis and breast engorgement
• History and physical examination - Gynecomastia
• History and physical examination - Breast nodule [Breast lump]
• History - Gynecomastia
• Differential Overview - Gynecomastia
• Differential Overview - Breast Mass/Discharge
• History - Gynecomastia
• History - Breast nodule
• Clinical Features and Diagnosis - Breast Enlargement
• Clinical Features and Diagnosis - Scrotal Enlargement
• History and physical examination - Gynecomastia
• History and physical examination - Breast nodule [Breast lump]
• Approach to the Diagnosis - Breast Discharge
• Approach to the Diagnosis - GYNECOMASTIA
• Gynecomastia - DIAGNOSIS - Gynecomastia

Diagnostic Tests for Gynecomastia: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Gynecomastia.

GYNECOMASTIA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there a history of drug ingestion? Digitalis, phenothiazine, amphetamine, marijuana, and many other drugs may cause gynecomastia.
2. Is there a testicular mass? Leydig's cell and Sertoli's cell tumors of the testicle may cause gynecomastia.
3. Are there abnormal secondary sex characteristics? Klinefelter's syndrome, male pseudohermaphroditism, and testicular feminization syndrome may cause gynecomastia.
4. Is there a bronze skin? If there is a bronze skin, one should consider hemochromatosis, as this may be associated with gynecomastia.
5. Are there other endocrine abnormalities? Cushing's syndrome, Addison's syndrome, and hyperthyroidism may cause gynecomastia.
6. Are there abnormalities on neurologic examination? Myotonic dystrophy, paraplegias of various types, and Friedreich's ataxia are among the many neurologic disorders that may be associated with gynecomastia.

DIAGNOSTIC WORKUP

A urine drug screen and thyroid profile should be done at the outset. Liver function studies, liver biopsy, and serum iron and iron-binding capacity will help rule out hemochromatosis and cirrhosis of the liver. A serum FSH, LH, HCG, and estradiol will help diagnose testicular tumors, Klinefelter's syndrome, and testicular feminization syndrome. Further evidence of Klinefelter's syndrome is obtained by a buccal smear (Barr bodies). Normal gonadotropin and sex hormone levels make serious pathology unlikely. A serum cortisol, cortisol suppression test, and rapid adrenocorticotropic hormone (ACTH) test will help diagnose Cushing's syndrome and Addison's disease. There is a specific beta-HCG assay that can be done to rule out an HCG-secreting tumor such as carcinoma of the lung.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

BREAST DISCHARGE: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is the discharge unilateral or bilateral? If it is unilateral and watery or bloody, one should look for a neoplasm in the breast. If it is bilateral and milky, one should look for the various conditions that cause hyperprolactinemia or pregnancy.
2. Is the discharge bloody? A unilateral bloody discharge is most suggestive of carcinoma of the breast. Other types of lesions of the breast, such as Paget's disease, papillary cystadenoma, and epithelioma of the nipple, are causes of a bloody discharge also.
3. Is there a focal mass in the breast? A bloody discharge with a focal mass makes a neoplasm almost certain. If there is a focal mass, fever, and a nonbloody discharge, one should consider abscess.
4. Is there fever? Fever or chills along with a purulent discharge from the breast is most likely acute mastitis or an abscess.

DIAGNOSTIC WORKUP

If there is a bloody discharge, one should not hesitate to refer the patient to a general surgeon, who will probably order mammography and perform a biopsy. The type of biopsy may be either a fine-needle aspiration or fine-needle biopsy or excisional biopsy, but the general surgeon can decide which is appropriate for any given patient. A unilateral nonbloody discharge may be studied further by ordering tests for occult blood, cytology, and mammography before referral. Remember that exploratory surgery may be the only way to get a diagnosis.

If the discharge is bilateral and milky, a serum prolactin should be ordered. If the prolactin is high, referral to an endocrinologist is probably the best step to take next. The endocrinologist will probably order a CT scan of the brain and pituitary and do further workup studies based on his examination.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Breast Pain & Discharge: Differential Diagnosis
(In a Page: Signs and Symptoms)

Breast pain

• Fibrocystic change
  –Most common benign breast condition
  –Clinically present in 50% and histologically in 90% of women
• Mastitis
  –Associated with lactation
• Extramammary causes of pain (e.g., cervical radiculitis, costochondritis, herpes zoster, angina)
• Breast cancer
  –Occurs in 1/9 women (lifetime risk)
• Cyst
• Breast abscess
• Unilateral or bilateral gynecomastia
• Phylloides tumor
• Intraductal papilloma
• Fat necrosis
• Trauma
• Fibroadenoma
• Lipoma
• Pregnancy
  Breast discharge
• Duct ectasia
• Galactorrhea
• Mondor's disease
• Chronic nipple stimulation
• Pregnancy
• Hypothyroidism
• Sarcoidosis
• Systemic lupus erythematosus
• Cirrhosis or other hepatic disease
• Breast cancer
  –Occurs in 1/9 women (lifetime risk)
• Intraductal papilloma
• Fibrocystic change
• Medications (e.g., phenothiazines, metoclopramide, tricyclic antidepressants, reserpine, opiates, cimetidine, androgens)
• Hypothalamic and pituitary abnormalities (e.g., prolactinoma, acromegaly, empty sella syndrome)
• Pseudocyesis

Workup and Diagnosis

• History includes past medical history, duration and pattern of pain and/or discharge, family history of breast or gynecologic cancer, and menstrual/pregnancy history

• Breast exam 7–9 days after menstrual flow
  –Fibrocystic areas: Slightly irregular, mobile, bilateral, upper outer quadrant; compression causes tenderness
  –Breast cancer: Solitary, irregular, or stellate; hard, nontender, fixed; not clearly delineated from surrounding tissue, ± lymphadenopathy
  –Mastitis: Inflamed, edematous, erythematous, indurated, tender areas, axillary lymphadenopathy
  –Nipple discharge: Bloody or serosanguinous discharge is suspicious for cancer; oral contraceptives, estrogens, or elevated prolactin levels may result in clear, serous, or milky discharge
• Diagnostic mammogram is indicated in patients >30 years old who present with solitary or dominant mass or asymmetric thickening
  –Compare with prior mammograms if possible
• Ultrasound is used to distinguish solid versus cystic
• Fine-needle aspiration, breast biopsy, cytologic exam of discharge, ductogram and/or galactogram may be indicated
• Endocrine evaluation may include prolactin levels, TSH, FSH, and LH

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Source: In a Page: Signs and Symptoms, 2004

Gynecomastia: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Pubertal
  –Prevalence 40–69% in adolescent males
  –Onset by 10–12 years old
  –Peaks at 13–14 years, Tanner III staging
  –Resolution in 1–2 years in 75%
  –Obese patients more affected

• Several drugs can cause gynecomastia
  –Antiandrogens: Flutamide, finasteride, ketoconazole, spironolactone
  –GI agents: Cimetidine, ranitidine
  –Calcium channel blockers: Verapamil, nifedipine
  –Illicit drugs: Marijuana, heroin, methadone, amphetamines
  –Hormones: Androgens, anabolic steroids, estrogens
  –Psychiatric: Phenothiazines, diazepam, tricyclic antidepressants

• Androgen insufficiency
  –Klinefelter syndrome (47, XXY)
  –Seminiferous tubule dysgenesis
  –Testicular failure
  –Androgen-insensitivity syndrome, androgen receptor defects
  –Biosynthetic defects in testosterone production
  –Isolated LH deficiency
• Excess estrogen
  –Feminizing adrenocortical tumors (rare)

• Testicular neoplasms
  –Germ cell tumors: Associated with hCG production; hCG leads to Leydig cell dysfunction and increased aromatase
  –Leydig cell tumors secrete estradiol
  –Sertoli cell tumors: Associated with excessive aromatase activity

• Pseudogynecomastia
  –Fat deposition without glandular development
  –Seen in obesity
• Other breast enlargement (not true gynecomastia)
  –Neurofibroma
  –Carcinoma of breast
  –Hemangioma
  –Lipoma
• Reifenstein syndrome
• Kallmann syndrome
• Liver cirrhosis

Workup and Diagnosis

• History
  –Breast characteristics
  –Duration
  –Progressive or regressing
  –Unilateral/bilateral
  –Associated erythema, tenderness, and/or discharge
  –Medication exposure
  –Change in appearance of testicles
  –Pubertal onset
  –Erectile function
  –Liver or kidney problems
• Physical exam
  –Abdominal exam for mass
  –Testicular exam for mass
  –Genital exam for Tanner staging
  –Chest exam for size and texture of tissue

• Labs
  –Investigation indicated for severe, prolonged, or sudden onset for the adolescent, for prepubertal boys, for pubertal boys with minimal viralization and/or small testes, and for child with CNS complaints
  –Karyotype
  –Serum gonadotropin (LH)
  –Serum testosterone
  –Serum estradiol
  –Serum hCG

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Enlarged Anterior Fontanelle: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Hypothyroidism
  –Primary congenital hypothyroidism occurs in 1/4,000 live births, more in females (2:1)
  –Ectopic thyroid gland is the most common etiology; may also be caused by thyroid dysgenesis, thyroid dyshormonogenesis, hypothalamic-pituitary hypothyroidism
  –Physical findings include prolonged jaundice, macroglossia, doughy skin, umbilical hernia, weak hoarse cry, hypotonia, poor feeding, sparse hair, dry skin, constipation, abdominal distension, poor growth, developmental delay, slow deep-tendon reflexes, broad flat nose
  –Acquired hypothyroidism is most commonly due to iodine deficiency or chronic autoimmune thyroiditis

• Increased intracranial pressure
  –Usually accompanied by increased head circumference
  –Hydrocephalus
  –Trauma
  –Acute CNS infections (meningitis or encephalitis)

• Skeletal dysplasias
  –Rickets
  –Achondroplasia
  –Osteogenesis imperfecta

• Genetic/chromosomal disorders
  –Down syndrome (trisomy 21): Associated with mental retardation, hypotonia, epicanthal folds, slanted palpebral fissures, small ears, Brushfield spots of iris, clinodactyly, single palmar crease, cardiac defects, brachycephaly, protruding tongue, short neck, large space between first and second toes
  –Apert syndrome
  –Trisomy 13
  –Trisomy 18
  –Silver-Russell syndrome
  –Cleidocranial dysostosis
  –Kenny syndrome

• Fetal hydantoin syndrome
• Intrauterine growth retardation
• Zellweger (cerebrohepatorenal) syndrome
• Hurler syndrome (type I mucopolysaccharidosis)

Workup and Diagnosis

• History
  –Birth history, including maternal health and medications, gestational age, perinatal fractures
  –Family history of any genetic or thyroid disease
  –History of trauma
  –Symptoms of hypothyroidism
• Physical exam
  –Growth parameters, including head circumference and growth percentiles
  –Signs of hypothyroidism
  –Dysmorphism associated with genetic abnormalities
• Labs
  –Check state newborn screening test results
  –Thyroid function tests (TSH, free T4)
  –Vitamin D, calcium, alkaline phosphatase levels for rickets
  –Chromosomes as indicated by H&P
  –Unrinary glycosaminoglycans for Hurler syndrome
  –Culture of blood and cerebrospinal fluid, including viral culture
  –Osteogenesis imperfecta: Molecular testing
  • Studies
    –Imaging of the head as indicated by H&P
    –X-rays of the skeletal system for rickets (rachitic rosary of the ribs, cupping of long bone metaphyses)
    –Thyroid scan or ultrasound

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Source: In A Page: Pediatric Signs and Symptoms, 2007

GYNECOMASTIA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

It is important to find out if the patient has been taking drugs of any kind. On physical examination, the physician may find bronze skin (a sign of hemochromatosis), a testicular mass, neurologic signs (suggesting Friedreich ataxia, myotonic dystrophy, paraplegia, etc.) or abnormal secondary sex characteristics (suggesting Klinefelter syndrome or pseudohermaphroditism). The laboratory workup should include a thyroid profile, liver profile, serum prolactin, urine drug screen, serum iron and iron binding capacity and serum FSH, LH, testosterone, and estradiol. Referral to an endocrinologist may be wise before ordering these expensive tests.

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Source: Differential Diagnosis in Primary Care, 2007

BREAST DISCHARGE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The workup of purulent breast discharge is usually simply a smear and culture and occasionally a white blood cell (WBC) count and differential. When these are fruitless, an acid–fast smear and culture may be indicated; however, this rarely occurs. It concerns me that tuberculosis is almost invariably given too much space in other differential diagnosis textbooks. Mammography is ordered next. For an endocrine workup, skull x-ray films, a CT scan or MRI of the brain, and serum prolactin levels may be done, but it is wise to refer the patient to an endocrinologist for further evaluation and diagnostic assessment.

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Source: Differential Diagnosis in Primary Care, 2007

Gynecomastia: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Begin the history by asking the patient when he first noticed his breast enlargement. How old was he at the time? Since then, have his breasts gotten progressively larger, smaller, or stayed the same? Does he also have breast tenderness or discharge? Have him describe the discharge, if any. Ask him if he’s ever had his nipples pierced. If so, were there any complications due to the piercings? Next, take a thorough drug history, including prescription, over-the-counter, herbal, and street drugs. Then explore associated signs and symptoms, such as testicular mass or pain, loss of libido, decreased potency, and loss of chest, axillary, or facial hair.

Focus the physical examination on the breasts, testicles, and penis. As you examine the breasts, note asymmetry, dimpling, abnormal pigmentation, or ulceration. Observe the testicles for size and symmetry. Then palpate them to detect nodules, tenderness, or unusual consistency. Look for normal penile development after puberty, and note hypospadias.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Breast nodule [Breast lump]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient reports a lump, ask her how and when she discovered it. Does the size and tenderness of the lump vary with her menstrual cycle? Has the lump changed since she first noticed it? Has she noticed other breast signs, such as a change in breast shape, size, or contour; a discharge; or nipple changes?

Is she breast-feeding? Does she have fever, chills, fatigue, or other flulike signs or symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in one breast only? Has she sustained recent trauma to the breast?

Explore the patient's medical and family history for factors that increase her risk of breast cancer. These include a high-fat diet, having a mother or sister with breast cancer, or having a history of cancer, especially cancer in the other breast. Other risk factors include nulliparity and a first pregnancy after age 30.

CULTURAL CLUE: Breast cancer incidence and mortality are about five times higher in North America and northern Europe than in Asia and Africa.

Next, perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.

Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule's delineation. Are the borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?

Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.

Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.

Be alert for a nipple discharge that's spontaneous, unilateral, and nonmilky (serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant. (See Breast nodule: Common causes and associated findings, page 106.)

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Mastitis and breast engorgement: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Confirming diagnosis  Diagnosis is usually easily made if pus is expressed from the nipple; culture may be helpful in confirming mastitis.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Gynecomastia: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin the history by asking the patient when he first noticed his breast enlargement. How old was he at the time? Since then, have his breasts gotten progressively larger, smaller, or stayed the same? Does he also have breast tenderness or discharge? Have him describe the discharge, if any. Ask him if he ever had his nipples pierced and, if so, if he developed any complications. Next, take a thorough drug history, including prescription, over-the-counter, herbal, and street drugs. Then explore associated signs and symptoms, such as testicular mass or pain, loss of libido, decreased potency, and loss of chest, axillary, or facial hair.

Focus the physical examination on the breasts, testicles, and penis. As you examine the breasts, note any asymmetry, dimpling, abnormal pigmentation, or ulceration. Observe the testicles for size and symmetry. Then palpate them to detect nodules, tenderness, or unusual consistency. Look for normal penile development after puberty, and note hypospadias.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Breast nodule [Breast lump]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If your patient reports a lump, ask her how and when she discovered it and whether its size and tenderness vary with her menstrual cycle. Has the lump changed since she first noticed it? Has she noticed any other breast signs, such as a change in breast shape, size, or contour; a discharge; or nipple changes?

Is she breast-feeding? If so, does she have fever, chills, fatigue, or other flulike signs or symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in one breast only? Has she sustained recent trauma to the breast?

Explore the patient’s medical and family history for factors that increase her risk of breast cancer. These include a high-fat diet, having a mother or sister with breast cancer, or having a history of cancer, especially cancer in the other breast. Other risk factors include nulliparity and a first pregnancy after age 30.

Cultural Cue: Breast cancer incidence and mortality are about five times higher in North America and northern Europe than in Asia and Africa.

Next, perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.

Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule’s delineation. Are its borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?

Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.

Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.

Be alert for a nipple discharge that’s spontaneous, unilateral, and nonmilky (serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant. (See Breast nodule: Causes and associated findings.)

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Gynecomastia: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Does the history suggest breast cancer or an underlying endocrine disorder? Are there immediately identifiable causes?

A. History. Persistent or rapid breast tissue enlargement may necessitate further evaluation if no diagnosis is apparent. Mild pain or tenderness by itself does not indicate a concerning underlying cause.

 B. Medications. Substances that can cause gynecomastia include alcohol, marijuana, androgens, estrogens, digitoxin, cimetidine, spironolactone, ketoconazole, and antiandrogens (1).

C. Medical disorders. Hyperthyroidism, renal failure, liver disease, starvation, or malnutrition can cause gynecomastia. Underlying cancers (lung, liver, kidney) can produce ectopic human chorionic gonadotropin (HCG), which stimulates aromatase activity.

 D. Endocrine disorders. Primary testicular failure and Klinefelter’s syndrome can be associated with gynecomastia.

Physical examination (PE)

 True gynecomastia is confirmed with the PE. With the patient supine, the breast is grasped between thumb and forefinger and the digits are moved toward the nipple. A firm, rubbery, mobile, disk-shaped mass of tissue beneath the nipple indicates true breast tissue enlargement. A focused PE can help exclude cancer of the breast or testes and some medical or endocrine disorders (Chapter 11.2).

 A. Pseudogynecomastia. Adipose tissue deposition produces the soft and poorly defined breast enlargement of pseudogynecomastia.

 B. Breast cancer. A unilateral, eccentric mass that is hard or firm, fixed to underlying tissue or associated with overlying skin dimpling, nipple discharge, or retraction, or axillary lymphadenopathy may represent breast cancer.

 C. Testicular examination. Congenital anorchia is a rare cause of gynecomastia. Bilateral small testes suggest gonadal failure. Testicular atrophy can result from alcohol abuse, mumps, leprosy, or other granulomatous disorders. Asymmetry or a palpable mass suggests testicular cancer (Chapter 10.7).

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Gynecomastia: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Adolescence

❑ Drugs

❑ Obesity

❑ Cirrhosis

❑ Chronic renal failure

❑ Hyperthyroidism

❑ Bilateral orchiectomy

❑ Ectopic hCG

❑ Primary hypogonadism

Diagnostic Approach

In true gynecomastia, a ridge of glandular tissue is palpable symmetrically beneath the areola. Gynecomastia must be distinguished from breast cancer, which is an eccentric firm mass with fixation, overlying skin dimpling, or nipple retraction, and regional adenopathy. Gynecomastia may be unilateral in one-third of cases, and it may be tender or painful.

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Source: Field Guide to Bedside Diagnosis, 2007

Breast Mass/Discharge: Differential Overview
(Field Guide to Bedside Diagnosis)

Breast Mass

❑ Fibrocystic disease

❑ Fibroadenoma

❑ Breast cancer

❑ Intraductal papilloma

❑ Mastitis

❑ Hematoma

❑ Thrombophlebitis

❑ Galactocele

Breast Discharge

❑ Drugs

❑ Postpartum lactation

❑ Prolactin-secreting pituitary adenoma

❑ Intraductal papilloma

❑ Fibrocystic disease

❑ Breast cancer

❑ Mammary duct ectasia

❑ Repeated nipple stimulation

Diagnostic Approach

Breast Mass: Breast lumps should be approached with a high index of suspicion for breast cancer, as approximately 20% of solitary or dominant breast masses are breast cancers. The physical examination is an important part of the diagnostic “triple test,” which includes mammography and fine needle aspiration cytology. When all three are positive, 99.4% have breast cancer. When all three tests suggest a benign lesion, only 0.7% have breast cancer.

Screening clinical breast examination detects approximately 50% of breast cancers. There is some but not total overlap with mammography; about 10% of screen-detected cancers are detected by physical examination and missed by mammography, while about 40% are detected by mammography and missed by physical examination. Techniques which increase the sensitivity of the examination include flattening of the breast against the chest wall (arm overhead), circular motions using the pads of the fingers, and spending greater time with the examination.

Cyclical pain and tenderness are usually due to fibrocystic disease. Although breast cancer can present with pain, it is often atypical and there is usually no tenderness. Characteristics of pain with alternative diagnoses include the following: heavy or full of milk (fibrocystic), sharp and radiating (radiculitis), itching, burning, drawing (duct ectasia), burning and stinging (mastodynia), sore, bruised, stabbing (trauma), throbbing (infectious), aching, and locally tender (costochondritis). Benign cysts are more prominent premenstrually and become smaller during the follicular phase of the menstrual cycle. Palpation characteristics suggestive of cancer include a mass that is firm, has indistinct borders, and has attachments to the skin or deep fascia. Dimpling of the skin, retraction of the nipple, bloody discharge from the nipple, and axillary nodal enlargement are all important clues to breast cancer.

Breast Discharge: Galactorrhea occurs when high levels of prolactin act upon a breast primed by estrogen and progesterone. Therefore, it is extremely rare in men unless there is a feminizing state. Milky discharge can usually be visually differentiated from a serous or bloody discharge. If confirmation is needed, microscopic examination for oval fat bodies (or use of Sudan stain) can be performed.

Bloody discharge is due to an ductal carcinoma (in situ or invasive) in one third of patients, a bleeding intraductal papilloma in another third, and fibrocystic breasts with an intraductal component (e.g. ductal ectasia, intraductal hyperplasia) in the remainder. All require further evaluation. When expressed by exam, discharge coming from one duct is more worrisome than discharge from multiple ducts. Bilateral multiductal discharge that is guaiac negative is usually benign regardless of color (milky, brown, green, yellow, blue, or clear), and due to an endocrine or physiologic process.

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Source: Field Guide to Bedside Diagnosis, 2007

Gynecomastia: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Begin the history by asking the patient when he first noticed his breast enlargement. How old was he at the time? Since then, have his breasts gotten progressively larger, smaller, or stayed the same? Does he also have breast tenderness or discharge? Have him describe the discharge, if any. Ask him if he’s ever had his nipples pierced and, if so, did he experience any complications as a result of the piercing? Next, take a thorough drug history, including prescription, over-the-counter, herbal, and street drugs. Then explore associated signs and symptoms, such as a testicular mass or pain, loss of libido, decreased potency, and loss of chest, axillary, or facial hair.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Breast nodule: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If your patient reports a lump, ask her how and when she discovered it. Does the size and tenderness of the lump vary with her menstrual cycle? Has the lump changed since she first noticed it? Has she noticed any other breast signs, such as a change in breast shape, size, or contour; a discharge; or nipple changes?

Is she breast-feeding? Does she have fever, chills, fatigue, or other flulike signs or symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in one breast only? Has she sustained recent trauma to the breast?

Explore the patient’s medical and family history for factors that increase her risk of breast cancer. These include a high-fat diet, having a mother or sister with breast cancer, or having a history of cancer, especially cancer in the other breast. Other risk factors include nulliparity and a first pregnancy after age 30.

CULTURAL CUE:Breast cancer incidence and mortality are about five times higher in North America and northern Europe than in Asia and Africa.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Breast Enlargement: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Infectious

Cellulitis/Abscess

Cellulitisor breast abscess can occur in the newborn.

Breast infections are unusual in adolescentgirls except for postpartum mastitis. Most common pathogen is S.aureus.

Breast is inflamed, painful, and tender.

Fluctuance is usually found with abscess.

Noninfectious

Infancy

Physiologic Hypertrophy

Transplacentalpassage of estrogen from mother to fetus causes unilateral or bilateral breasthypertrophy in the newborn, which is usually apparent during firstweek of life.

Hypertrophy usually resolves withina few months but sometimes persists until 1 or 2 yrs of age.

If breast enlargement does not progressand growth velocity remains normal, no other investigation is necessary.

Childhood

Premature Thelarche

Definedas breast enlargement (unilateral or bilateral) that occurs withoutother pubertal changes.

Resolution occurs in a few months ormay persist until puberty.

See Chap.48, Precocious Puberty.

Precocious Puberty

Exists whensigns of sexual development besides breast development occur, includingdevelopment of axillary and pubic hair, accelerated growth, andonset of menses.

See Chap.48, Precocious Puberty.

Gynecomastia

Male breastenlargement is uncommon before puberty.

Cause in most cases is idiopathic.Unusual causes include exogenous estrogen exposure and tumors (adrenal,testicular).

Obese boys often appear to have breastenlargement, but no breast tissue is palpable.

Adolescence

Girls

Cysts

Single ormultiple breast cysts may cause mild pain and tenderness.

U/S can confirm diagnosis.

Trauma

Contusionto the breast may produce firm, tender, diffuse mass, whereas hematoma ismore sharply defined.

Fat necrosis may develop after traumaas firm, superficial mass that does not enlarge but resolves slowlywith time.

Macromastia

Defined as development of large but histologicallynormal breasts.

Juvenile Hypertrophy

Definedas breast enlargement secondary to marked increase in fibrous connective tissueand ductal proliferation.

Breasts are firm and may be nodular.

Fibrocystic Disease

Fibrocysticchanges of one or both breasts are physiologic response to cyclichormonal stimulation.

Pain and tenderness usually occur justbefore menstrual period as cysts enlarge. Cordlike thickenings andcystic masses may be palpable. Nonbloody nipple discharge also maybe seen.

Usually diagnosed clinically; however,U/S can confirm cystic nature of masses.

Neoplasm

Benign

Most commonbreast mass found in girls is fibroadenoma, which usually occursin adolescence and can be multiple and bilateral.

Discrete, mobile, nontender, firm massesare usually 2–3 cm in diameter. Larger ones that are 10–15cm in diameter may need excision. Otherwise, these tumors can befollowed clinically.

Besides fibroadenoma, breast tumorsare rare in childhood and adolescence. Ductal papilloma usuallyappears as nodule beneath areola, and firm pressure may producebrown or bloody fluid. Lipomas and lymphangiomas appear as soft,painless breast masses.

Cystosarcoma phyllodes is firm, circumscribedmass with occasional nipple discharge. Often benign but may be malignant.

Malignant

Rare inpediatric population.

Primary tumors include carcinomas,lymphomas, and sarcomas.

Carcinoma of breast usually appears as unilateral,firm mass that adheres to skin and sometimes produces dischargeor bleeding from nipple.

Sarcomas also present as firm, unilateral,breast masses.

Metastatic lesions from leukemia, lymphoma,rhabdomyosarcoma, and neuroblastoma also occur.

Malignancy should be suspected wheneverunilateral, hard, fixed, rapidly growing breast mass is noted.

Only way to make definitive diagnosisis by biopsy.

Boys

Physiologic Gynecomastia

Any growthof breast tissue in males is called gynecomastia, a common occurrence inadolescence.

Mechanism of enlargement is thoughtto be increased ratio of estrogens to androgens or change in sensitivityof breast tissue receptors during puberty.

Palpable breast tissue involving 1or both breasts is 1–2 cm in diameter.

Enlargement usually lasts for 1–2years and gradually recedes.

Drugs

Drugs that have been implicated in causingbreast enlargement in girls before puberty and in boys include

Hormones(estrogens, estrogen agonists, androgens, anabolic steroids, chorionicgonadotropin)

Psychoactive agents (tricyclic antidepressants,diazepam, phenothiazines, haloperidol)

Cardiovascular drugs (captopril, enalapril,verapamil, nifedipine, digitoxin)

Diuretics (thiazides, spironolactone)

Antibiotics (isoniazid, ketoconazole,metronidazole)

Cytotoxic drugs (vincristine, cyclophosphamide,methotrexate)

Gastric acid inhibitors (ranitidine,cimetidine, omeprazole)

Drugs of abuse (alcohol, heroin, methadone,marijuana, amphetamines)

Others (phenytoin, penicillamine)

Klinefelter Syndrome

Adolescentboys with Klinefelter syndrome are tall and have small testes. Gynecomastiamay occur but is not evident until puberty.

Serum concentrations of follicle-stimulatinghormone (FSH) and luteinizing hormone (LH) are elevated.

Most common karyotype is 47,XXY.

Neoplasm

Althoughprimary breast tumors in boys are rare, they may be benign (hemangioma, lipoma,lymphangioma, neurofibroma) or malignant (carcinoma). Malignanttumor should be suspected with irregular, hard, fixed mass; bloodynipple discharge; and axillary adenopathy.

Leydig cell testicular tumors secreteestrogen and can present with gynecomastia and precocious puberty.Testicular mass is usually palpable.

Adrenal estrogen-producing tumors (adenoma,carcinoma) are rare but may cause gynecomastia. Abdominal U/Sand CT are useful in locating tumor mass.

hCG-secreting germ cell tumors stimulateandrogen and estrogen production in testes and may present withgynecomastia and precocious puberty.

Other

Gynecomastia also may be associated withcystic fibrosis, ulcerative colitis, chronic liver disease, hypothyroidism,hyperthyroidism, and HIV infection.

Diagnostic Approach

Historyand physical exam are diagnostic in many cases of breast enlargement.

Important features are gender, ageof onset, history of drug ingestion, signs of infection, whetherphysical and sexual development are normal, stage of sexual development,and presence of breast mass.

Girls

Before puberty,except for the newborn, premature thelarche and precocious puberty aremost common causes of breast enlargement.

Girls with unilateral subareolar massesin early puberty usually have normal enlarging breast bud, and excisionalbiopsy should be avoided.

In pubertal girl suspected of havingfibrocystic disease, clinical observation for 3 menstrual cyclesis appropriate.

Nature of discrete palpable mass (solidvs cystic) can be determined by U/S. Needle aspirationcan be considered if mass persists.

Palpable mass that cannot be delineatedby imaging should be followed and excisional biopsy should be considered.

Boys

Before puberty,breast enlargement is rare.

In obese boys, breasts seem to be enlargedbut no breast tissue is palpable.

In pubertal boys, most common causeof breast enlargement is physiologic.

Body habitus and testicular size shouldbe noted. If testes are small and serum concentrations of FSH andLH are elevated, diagnosis is almost certainly Klinefelter syndrome.Chromosomal karyotype confirms diagnosis.

Drugs, chronic liver disease, and neoplasmsare rare causes of breast enlargement in boys during childhood andadolescence.

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Scrotal Enlargement: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Painful Scrotal Enlargement

Testicular

Torsion of Testis

Twistingof spermatic cord causes diminished blood flow to testis and acutescrotal pain. Lower abdominal pain and vomiting also may occur.Tender, swollen testis is located higher in scrotum, and cremastericreflex is usually absent.

History of intermittent bouts of scrotalpain may indicate previous intermittent torsion.

In many cases, diagnosis can be madeclinically and should be confirmed by prompt surgical exploration.If diagnosis is uncertain, procedure of choice to determine testicularperfusion is U/S with color flow Doppler.

Orchitis

May existas isolated viral infection (mumps virus is most common) or as extension ofepididymitis.

Unusual before puberty.

1 or both testes are swollen and painful.

With mumps infection, orchitis usuallyoccurs a few days after onset of parotitis.

Trauma

Trauma toscrotum may produce a spectrum of disease, including mild swelling,hematoma formation, or rupture of testis with blood in scrotum.

U/S is procedure of choiceto assess structural integrity of scrotum.

Nontesticular

Torsion of Appendages of Testis and Epididymis

Attachedto the testis and epididymis are vestiges of embryologic remnantsthat can twist around their base, producing infarction. This iscalled torsion of appendix testis or appendix epididymis.

Usual age of occurrence is school agebefore adolescence. Pain is usually not as severe as with torsionof testis and develops over a few days. Tender bluish nodule signifyingtorsion of appendix testis is often seen at superior lateral aspectof testis. Torsion of appendix epididymis occurs at head of epididymis.

This is often clinical diagnosis; however,scrotal U/S should be performed if diagnosis is uncertain.

Epididymitis

Most commonin adolescents who are sexually active, whereas younger boys tendto have associated urinary tract infection.

Scrotal pain and swelling as well asepididymal tenderness are usual findings. Early in illness, it maybe possible to distinguish epididymis from testis, but this maybe impossible with progression of inflammation and swelling.

If diagnosis is uncertain, scrotalU/S with color flow Doppler can be performed. UA and urineculture also should be performed.

After course of appropriate treatmentin older age group, if dysfunctional voiding exists, urinary urodynamictesting should be performed. In younger age group after course ofappropriate treatment, renal U/S and contrast voiding cystourethrographyshould be performed, because urinary tract anomalies (e.g., posteriorurethral valves or ectopic ureter emptying into seminal vesicle)may occur.

Incarcerated Inguinal Hernia

Painful,tender mass is palpable in inguinal area with extension at timesinto scrotum.

If hernia cannot be reduced, compromiseof bowel may occur, and surgery should be performed immediately.If hernia can be reduced, surgery is usually performed in a fewdays, after swelling has decreased.

Nonpainful Scrotal Enlargement

Testicular

In Utero Torsion

Poor fixationof spermatic cord during fetal life predisposes to in utero torsionof testis during testicular descent.

Firm testicular mass is discolored,and salvage of infarcted testis is unlikely.

Although some controversy exists aboutmanagement, exploration and contralateral orchiopexy are performedelectively in our hospital once infant is stable.

Tumor

Testiculartumors are rare in children and usually present as painless, firmto hard, testicular masses. Most common ones include yolk sac tumor,teratoma, and testis infiltration with leukemia or non-Hodgkin lymphoma.

Scrotal U/S can confirm presenceof testicular tumor. Histologic diagnosis is definitive.

Nontesticular

Inguinal Hernia

May extend into scrotum and produce enlargedscrotum. Increased intraabdominal pressure with crying or strainingmay produce recurrent episodes of painless inguinal and scrotalswelling. Although reduction is usually easy, hernia should be repairedto prevent incarceration.

Hydrocele

Fluid withintunica vaginalis surrounding testis is called a hydrocele. Becausepatent processus vaginalis permits communication with abdominalcavity, hydrocele may change in size because of changing amountof fluid in scrotum.

Communicating hydrocele tends to persistand may lead to development of inguinal hernia if diameter of processusbecomes larger. Closed processus results in formation of noncommunicatinghydrocele. Its size does not fluctuate, and fluid often disappearsby 1 yr of age.

Hydrocele of spermatic cord may presentas fluid-filled inguinal canal mass.

Occasionally, hydrocele may occur inolder children secondary to trauma, inflammation, or testiculartumor.

U/S is helpful if diagnosisis uncertain.

Spermatocele

Is a sperm-containing cyst of rete testes,ductuli efferentes, or epididymis. It is nontender, usually <1cm in diameter, and located posterior and superior to testis inpostpubertal boys. Aspiration yields milky fluid composed of spermcells. Surgery may be required if cyst is painful.

Varicocele

Group ofdilated, elongated spermatic cord veins, which may be seen in boys10–15 yrs of age. Most varicoceles occur on left side.

Scrotum is enlarged and sometimes painful.Mass is often described as bag of worms. Veins are palpable on standingbut collapse and disappear in supine position. Valsalva maneuveror coughing also may cause varicocele to become more apparent.

Presence of testicular atrophy on affectedside is indication for surgery because of possible occurrence ofinfertility.

Henoch-Schönlein Purpura

Purpuric rash in this disorder typicallyoccurs on buttocks and lower legs. Occasionally, rash may involvescrotum and cause some swelling. See Chap.28, Hematuria.

Kawasaki Disease

Scrotal swelling also may occur with Kawasakidisease, which is discussed in Chap.21, Fever.

Meconium Peritonitis

Intestinalperforation is cause of antenatal meconium peritonitis. Meconiumpasses along patent processus vaginalis into scrotum, and bilateralneonatal hydroceles may be palpable as firm nodular masses on 1or both sides of scrotum.

Abdominal radiography that includesscrotum demonstrates calcifications in scrotum as well as underdiaphragm. U/S also may confirm diagnosis.

Tumors of Epididymis, Spermatic Cord, or Scrotal Wall

Benign tumorsinclude lipoma, fibroma, leiomyoma, and lymphangioma. Paratesticularrhabdomyosarcoma is of most concern.

U/S can help locate and defineextent of tumor.

Histologic diagnosis is definitive.

Generalized Edema

Scrotal edema may occur as part of generalizededema, which is discussed in Chap.17, Edema. Testis and spermatic cord are normal.

Diagnostic Approach

Cause ofscrotal enlargement often can be determined clinically based onhistory and physical exam. Age of child, type of presentation (acuteor chronic, unilateral or bilateral), and presence of scrotal ortesticular pain or testicular enlargement are distinguishing featuresuseful in diagnosis.

Torsion of testis, torsion of appendixtestis, and epididymitis often can be distinguished clinically earlyin clinical course. With progression of disease process, this maynot be possible. If diagnosis is uncertain, U/S with colorflow Doppler should be performed. Surgical exploration is indicatedwhenever there is high suspicion of torsion of testis.

Transillumination can help distinguishsolid or cystic lesions, but incarcerated inguinal hernia also cantransilluminate.

U/S can determine whethermass is testicular or nontesticular and can distinguish solid from cysticlesions.

Nontesticular cystic lesions are usuallybenign and can be managed according to specific diagnosis. Testicularmass is assumed to be malignant tumor until proven otherwise.

>

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Gynecomastia: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Begin the history by asking the patient when he first noticed his breast enlargement. How old was he at the time? Since then, have his breasts gotten progressively larger, smaller, or stayed the same? Does he also have breast tenderness or discharge? Have him describe the discharge, if any. Ask him if he's ever had his nipples pierced. If so, were there any complications due to the piercings? Next, take a thorough drug history, including prescription, over-the-counter, herbal, and street drugs. Then explore associated signs and symptoms, such as testicular mass or pain, loss of libido, decreased sexual potency, and loss of chest, axillary, or facial hair.

Focus the physical examination on the breasts, testicles, and penis. As you examine the breasts, note asymmetry, dimpling, abnormal pigmentation, or ulceration. Observe the testicles for size and symmetry. Then palpate them to detect nodules, tenderness, or unusual consistency. Look for normal penile development after puberty, and note hypospadias.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Breast nodule [Breast lump]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient reports a lump, ask her how and when she discovered it. Does the size and tenderness of the lump vary with her menstrual cycle? Has the lump changed since she first noticed it? Has she noticed other breast signs, such as a change in breast shape, size, or contour; a discharge; or nipple changes?

Is she breast-feeding? Does she have fever, chills, fatigue, or other flulike signs or symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in one breast only? Has she sustained recent trauma to the breast?

Explore the patient's medical and family history for factors that increase her risk of breast cancer. These include having a mother or sister with breast cancer or having a history of cancer, especially cancer in the other breast. Other risk factors include nulliparity and a first pregnancy after age 30.

Next, perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.

Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule's delineation. Are the borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?

Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.

Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.

Be alert for a nipple discharge that's spontaneous, unilateral, and nonmilky (for example, serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Breast Discharge: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The workup of purulent breast discharge is usually simply a smear and culture and occasionally a white blood cell (WBC) count and differential. When these are fruitless, an acid-fast smear and culture may be indicated; however, this rarely occurs. It concerns me that tuberculosis is almost invariably given too much space in other differential diagnosis textbooks. Mammography is ordered next. For an endocrine workup, skull x-ray films, a CT scan or MRI of the brain, and determination of serum prolactin levels may be done, but it is wise to refer the patient to an endocrinologist for further evaluation and diagnostic assessment.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

GYNECOMASTIA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

It is important to find out if the patient has been taking drugs of any kind. On physical examination, the physician may find bronze skin (a sign of hemochromatosis), a testicular mass, neurologic signs (suggesting, e.g., Friedreich ataxia, myotonic dystrophy, paraplegia) or abnormal secondary sex characteristics (suggesting Klinefelter syndrome or pseudohermaphroditism). The laboratory workup should include a thyroid profile, liver profile, serum prolactin, urine drug screen, serum iron and iron binding capacity, and serum FSH, LH, testosterone, and estradiol. Referral to an endocrinologist may be wise before ordering these expensive tests.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Gynecomastia: Gynecomastia - DIAGNOSIS
(The 5-Minute Pediatric Consult)

• Do not mistake pseudogynecomastia (i.e., fatty enlargement of the breasts) for true gynecomastia.
• Do not overlook a potentially drug-related cause. Drug-related gynecomastia is usually reversible if diagnosed within 1 year of onset.

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008

 » Next page: Signs of Gynecomastia

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