Nipple discharge
Nipple discharge: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
Nipple discharge can occur spontaneously or can be elicited by nipple stimulation. It’s characterized as intermittent or constant, as unilateral or bilateral, and by color, consistency, and composition. Its incidence increases with age and parity. This sign rarely occurs (but is more likely to be pathologic) in men and in nulligravid, regularly menstruating women. It’s relatively common and usually normal in parous women. A thick, grayish discharge — benign epithelial debris from inactive ducts — can commonly be elicited in middle-age parous women. Colostrum, a thin, yellowish or milky discharge, typically occurs in the last weeks of pregnancy.
Nipple discharge can signal serious underlying disease, particularly when accompanied by other breast changes. Significant causes include endocrine disorders, cancer, certain drugs, and blocked lactiferous ducts.
History
Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency. Is the patient taking hormones (hormonal contraceptives or hormone replacement therapy)? Is the discharge spontaneous, or does it have to be expressed?
Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last menses. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for any risk factors of breast cancer — family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.
Physical assessment
Start your physical assessment by characterizing the discharge. If the discharge isn’t frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d’orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
Medical causes
Breast abscess
A breast abscess, most common in breast-feeding women, may produce a thick, purulent discharge from a cracked nipple or an infected duct. Associated findings include abrupt onset of high fever with chills; breast pain, tenderness, and erythema; a palpable soft nodule or generalized induration; and, possibly, nipple retraction.
Breast cancer
Breast cancer may cause bloody, watery, or purulent discharge from a normal-appearing nipple. Characteristic findings include a hard, irregular, fixed lump; erythema; dimpling; peau d’orange; changes in contour; nipple deviation, flattening, or retraction; axillary lymphadenopathy; and, possibly, breast pain.
Choriocarcinoma
Galactorrhea (a white or grayish milky discharge) may result from choriocarcinoma, a highly malignant neoplasm that can follow pregnancy. Other characteristics of choriocarcinoma include persistent uterine bleeding and bogginess after delivery or curettage, and vaginal masses.
Herpes zoster
Herpes zoster can stimulate the thoracic nerves, causing bilateral, spontaneous, intermittent galactorrhea. Other characteristics include shooting or burning pain, eruption of small red nodules or vesicles on the thorax and possibly the arms and legs, pruritus and paresthesia or hyperesthesia in affected areas, headache, and fever and malaise.
Intraductal papilloma
Intraductal papilloma is the primary cause of nipple discharge in the nonpregnant, non-breast-feeding woman. Unilateral serous, serosanguineous, or bloody nipple discharge — usually from only one duct — is its predominant sign. Discharge may be intermittent or profuse and constant, and can usually be stimulated by gentle pressure around the areola. Subareolar nodules, breast pain, and tenderness may occur.
Mammary duct ectasia
A thick, sticky, grayish discharge from multiple ducts may be the first sign of mammary duct ectasia. The discharge may be bilateral and is usually spontaneous. Other findings include a rubbery, poorly delineated lump beneath the areola, with a blue-green discoloration of the overlying skin; nipple retraction; and redness, swelling, tenderness, and burning pain in the areola and nipple.
Paget’s disease
With Paget’s disease, serous or bloody discharge emits from denuded skin on the nipple, which is red, intensely itchy and, possibly, eroded or excoriated. The discharge is usually unilateral.
Prolactin-secreting pituitary tumor
Bilateral galactorrhea may occur with this tumor. Other findings include amenorrhea, infertility, decreased libido and vaginal secretions, headaches, and blindness.
Proliferative (fibrocystic) breast disease
Proliferative (fibrocystic) breast disease is a benign disorder that occasionally causes a bilateral clear, milky, or straw-colored discharge, which is rarely purulent or bloody. Multiple round, soft, tender nodules are usually palpable in both breasts, although they may occur singly. Usually, nodules are mobile and are located in the upper outer quadrant. Nodule size, tenderness, and discharge increase during the luteal phase of the menstrual cycle. Symptoms then regress after menses.
Trauma
Bilateral galactorrhea can result from trauma to the breasts. Depending on the cause and severity of the chest trauma, the patient may also have chest pain, dyspnea, bruising, flail chest, cardiac tamponade, pulmonary artery tears, ventricular rupture, shock, and bronchial, tracheal, or esophageal tears or rupture.
Other causes
Drugs
Galactorrhea can be caused by psychotropic agents, particularly phenothiazines and tricyclic antidepressants; some antihypertensives (reserpine and methyldopa); hormonal contraceptives; cimetidine; metoclopramide; and verapamil.
Surgery
Chest wall surgery may stimulate the thoracic nerves, causing intermittent bilateral galactorrhea.
Special considerations
Although nipple discharge is usually insignificant, it can be frightening to the patient. Help relieve the patient’s anxieties by clearly explaining the nature and origin of her discharge. Apply a breast binder, which may reduce discharge by eliminating nipple stimulation.
Diagnostic tests may include tissue biopsy (if a breast lump is found), cytologic study of the discharge, mammography, ultrasonography, transillumination, and serum prolactin.
Pediatric pointers
Nipple discharge in children and adolescents is rare. When it does occur, it’s almost always nonpathologic, as in the bloody discharge that sometimes accompanies onset of menarche. Infants of both sexes may experience a milky breast discharge beginning 3 days after birth and lasting up to 2 weeks due to maternal hormonal influences.
Geriatric pointers
In postmenopausal women, breast changes are considered malignant until proven otherwise.
Patient counseling
Counsel your patient to be aware of discharge characteristics, including its consistency (thick or thinning), odor, origin (in single or multiple ducts), and relation to the menstrual cycle. If the discharge becomes bloody, instruct the patient to seek medical evaluation. Instruct the patient to perform breast self-examinations and to maintain appointments for breast examinations by a physician and for mammograms as recommended.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Medical Books Excerpts
- Nipple Discharge
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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