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)
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