Nipple Discharge
Nipple Discharge: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Joyce A. Copeland
Approach
The evaluation of a nipple discharge in the nonpregnant female patient helps determine if the cause is physiologic, pathologic, or is a “pseudodischarge,” and to assess the risk of malignancy.
History
A. Presentation. How old is the patient? When and how was the discharge first discovered? Discharges that have been apparent for longer periods of time are more likely to be benign. The risk of cancer increases with advancing age.
B. Discharge characteristics. What is the color and consistency of the discharge? Is the discharge spontaneous or associated with manipulation or sexual activity only? Is the discharge unilateral or bilateral, uniductal or multiductal? What part of the nipple is affected?
1. A bloody, red discharge or a discharge that has the appearance of old blood is suggestive of, but not specific to, breast cancer.
2. A spontaneous, unilateral, uniductal discharge raises the level of suspicion for cancer. This does not exclude cancer from the differential diagnosis in the multiductal presentation.
C. Pain. Cyclic pain suggests a physiologic cause. Continuous pain and burning may indicate pathology related to inflammation (e.g., ductal ectasia or infection).
D. Reproductive history. What is the patient’s menstrual history? Has she had a recent pregnancy or abortion? Amenorrhea or irregular menses in a premenopausal woman with a nipple discharge suggests the need to evaluate the patient for pregnancy, hypothyroidism, or a disruption of the hypothalamic-pituitary axis (Chapters 11.1 and 11.5).
E. Medical history. Is there a history of significant chest wall trauma? Is there a recent history of herpes zoster infection? Does she have a history of atopic dermatitis? Does the patient have a history of breast cancer or breast surgery?
1. Chest wall trauma (e.g., a thoracotomy) and herpes zoster infection have been reported to cause nipple discharge.
2. Any systemic disease that affects the hypothalamic-pituitary axis or alters the clearance of prolactin can result in hyperprolactinemia. Visual disturbance or headache can be associated with the presence of a pituitary adenoma.
F. Medication. Is the patient taking any medications? Offending agents include:
1. Phenothiazines, haloperidol, and numerous other antipsychotics
2. Tricyclic antidepressants, benzodiazepines, selective serotonin reuptake inhibitors
3. Metoclopramide, cimetidine
4. Reserpine, methyldopa, digitalis, verapamil
5. Oral contraceptives, estrogens, progestins
6. Heroin, marijuana, amphetamines, cocaine
7. Isoniazid, danazol
G. Activity and lifestyle. Is the patient a jogger or does she participate in aerobic exercise? Does she smoke; if so, how much? Has the patient deliberately manipulated or traumatized the nipple? Friction of clothing on the nipple can create discharge, bleeding, and tenderness, which can result in bleeding, crusting, or traumatic erosions. Smoking increases the risk of cancer and ductal ectasia.
H. Family history. Is there a family history of breast cancer?
I. Review of symptoms. A review of systems for thyroid, renal, liver, adrenal, or pituitary disease should be included in the query. Ask about visual disturbances or headache, which can be associated with a pituitary adenoma.
Physical examination
A. Clinical breast examination (Chapter 11.2)
1. Inspection. Observe the skin of the breast for crusting or a rash on the nipple or areolar region. Document the color of any discharge. Look for evidence of nipple retraction. Locate the site of the discharge on the nipples. Magnification can assist localization. Look for chest wall scars, evidence of viral infections (e.g., herpes zoster or simplex), and signs of eczema or inflammation.
2. Palpation. Feel the skin surface for warmth in the presence of erythema. Palpate both breasts for evidence of a mass or tenderness. Palpate regional nodes for evidence of lymphadenopathy (Chapters 11.2 and 15.2).
3. Compression. Compress the nipple and areolar area of both breasts with the thumb and index finger in an effort to elicit a discharge. Perform this examination in several directions. Note the location of any discharge and the number of ducts involved, as well as whether the discharge is unilateral or bilateral.
B. Other examination components. Palpate the thyroid and liver if history indicates the need. Perform a neurologic examination, including visual fields, in patients with visual disturbance or headache.
Testing
A. Clinical laboratory. Order blood tests looking for evidence of thyroid, renal, and liver diseases or establishing a prolactin level, based on clinical history.
B. Discharge. Test for occult blood if blood is not readily apparent. The specificity and sensitivity of cytology limits its effectiveness and is not necessary.
C. Imaging. Mammography is indicated to look for nonpalpable masses or calcifications. Ductography may help distinguish the location of ductal pathology in a localized discharge but is not a substitute for exploration of the ductal system.
D. Ductal exploration. The patient who does not have a good physiologic explanation for her discharge should be referred for surgical exploration or biopsy.
Diagnostic assessment (1,2)
A. Categories of risk. The four categories of risk described by Arnold and Neiheisel include lactation, physiologic, pathologic, and false discharge (1).
1. Physiologic discharges are usually bilateral, multiductal, painless, and associated with either stimulation of the nipple or medications. Color may be white, yellow, gray, or green, and the consistency is usually milky. Occasionally, blood is present.
2. Pathologic discharges are usually unilateral, uniductal, and spontaneous. Color is variable and blood or purulence may be apparent. Cancer, benign tumors, infections, and systemic disease are pathologic causes of discharges of this type.
3. Pseudodischarge. A false discharge is often associated with staining on clothing or crusting on the nipple. This is different from the “droplets” of a true discharge. Eczema, viral infections (herpes zoster or simplex), or Paget’s disease can cause a pseudodischarge.
B. Specific disorders of interest
1. Intraductal papilloma is the most common cause of benign pathologic discharges.
2. Ductal ectasia is the result of a progression of ductal stagnation and resultant inflammatory process. The incidence of this disorder is higher in smokers and is most prominent in those aged 40 to 60 years. Induration and noncyclic burning pain are characteristic of this disorder.
3. Paget’s disease involves the skin of the nipple and areola. It is usually associated with ductal carcinoma. Send any areolar lesion that does not respond to antibiotics or topical treatment for biopsy to exclude this disorder.
References
1. Arnold G, Neiheisel M. A comprehensive approach to evaluating nipple discharge. Nurse Pract 1997;22(7):96–108.
2. Andolsek K, Copeland J. Conditions of the breast. In: Taylor RB, ed. Family medicine: principles and practice, 5th ed. New York: Springer-Verlag, 1998.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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