Nipple discharge
Nipple discharge: Excerpt from Nursing: Interpreting Signs and Symptoms
Nipple discharge can occur spontaneously or can be elicited by nipple stimulation. It's characterized as intermittent or constant, 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 typically normal in parous women. A thick, grayish discharge—benign epithelial debris from inactive ducts—can usually be elicited in middle-aged parous women. Colostrum, a thin, yellowish or milky discharge, commonly 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 and physical examination
Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Is the discharge spontaneous or does it have to be expressed? 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. Ask about other symptoms, such as fever and malaise.
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 risk factors of breast cancer—family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.
Is the patient taking hormones (such as hormonal contraceptives or hormone replacement therapy), antihypertensives, or psychotropic drugs?
Start your physical examination 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.Breast abscess may produce a thick, purulent discharge from a cracked nipple or infected duct. Associated findings include an abrupt onset of a 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 this highly malignant neoplasm, which can follow pregnancy. Other characteristics include persistent uterine bleeding and bogginess after delivery or curettage and vaginal masses.
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 prolactin-secreting pituitary tumor. Other findings include amenorrhea, infertility, decreased libido and vaginal secretions, headaches, and blindness.
Proliferative (fibrocystic) breast disease.Proliferative breast disease 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.
Other causes
Drugs.Galactorrhea can be caused by psychotropic agents, particularly phenothiazines and tricyclic antidepressants; some antihypertensives (such as reserpine and methyldopa); hormonal contraceptives; cimetidine; metoclopramide; and verapamil.
Surgery.Chest wall surgery may stimulate the thoracic nerves, causing intermittent bilateral galactorrhea.
Nursing considerations
▪ Apply a breast binder, which may reduce discharge by eliminating nipple stimulation.
▪ Prepare the patient for diagnostic tests such as tissue biopsy (if a breast lump is found), cytologic study of the discharge, mammography, ultrasonography, transillumination, and serum prolactin level.
Patient teaching
▪ Explain when to seek medical attention.
▪ Discuss the importance of breast self-examination, medical appointments, and mammograms.
▪ Explain the nature and origin of the patient's nipple discharge and the treatment plan.
Pictures
Book Source Details
- Book Title: Nursing: Interpreting Signs and Symptoms
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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