Approach to nipple discharge

Question 1

What is the history to elicit

Answer 1

1. Is the discharge from the nipple, or eczema/paget’s
2. Is the discharge pathological?
   - Unilateral, uniductal, spontaneous, bloody, persistent discharge worrying
3. Pregnancy? Discharge >1 year worrying
4. Troubling?

Question 2

How to differentiate paget’s disease from eczema of nipple?

Answer 2

1. Unilateral (P) or bilateral (eczema)
2. Distinct edges (P) vs indistinct (E)
3. Non itch (P) vs itch (E)
4. Menopause vs lactation
5. Vesicles absent vs present
6. Nipple destruction vs intact
7. Underlying lump usually present in pagets

Question 3

What is pathological nipple discharge?

Answer 3

Serous, Sanguineous (bloody) or blood tinged discharge which is

• Spontaneous
• Uniductal
• Unilateral
• Persistent (more than twice a week)
• Palpable abnormality
• In an older person

Question 4

What are the differentials for grossly bloody discharge?

Answer 4

1. Mostly intraductal papilloma (benign breast tumour from epithelium of ducts)

Mammogram/palpation usually yields nothing (small lump). Must perform ductogram, and treat with excision

2. Fibrocystic change - follow up with triple assessment
3. Mammary ductal carcinoma - invasive or DCIS

Question 5

What are the differentials for clear discharge?

Answer 5

Intraductal papilloma/ductal carcinoma

Mammary duct ectasia

Question 6

What are differentials of green/brown/black discharge?

Answer 6

Cell debris from mammary ductal ectasia - a benign, self limiting condition where ducts get dilated, inflammed and fibrosed

Question 7

What are differentials for purulent or foul smelling discharge?

Answer 7

Lactational mastitis or breast abscess, usually caused by staph aureus

Rule out inflammatory breast cancer with biopsy, treat with aspiration and antibiotics

Question 8

What are the differentials of white milky discharge?

Answer 8

Galactorrhea/lactation

Question 9

What are the differentials for blood stained discharge?

Answer 9

Paget’s disease/eczema