Breast, nipple discharge

Question 1

Probability diagnosis

Answer 1

Pregnancy

Physiological

Intraduct papilloma

Lactation/lactation cysts

Mammary dysplasia

Question 2

Serious disorders not to be missed

Answer 2

Infection:

• acute mastitis/discharging breast abscess
• areolar abscess (infected gland of Montgomery)
• tuberculosis abscess

Cancer:

• intraduct carcinoma
• invasive carcinoma
• Paget disease of nipple

Other:

• hyperprolactinaemia

Question 3

Pitfalls (often missed)

Answer 3

Mammary duct ectasia

Drugs e.g.

• chlorpromazine
• metoclopramide
• OCP
• cimetidine
• opiates
• amphetamines
• CCBs
• tricyclic antidepressants
• phenothiazine

Rarities:

• mammary duct fistula
• mechanical stimulation

Question 4

Masquerades checklist

Answer 4

Drugs (as above)

Endocrine: hyperprolactinaemia, hypothyroidism

Question 5

Key history

Answer 5

FHx of breast disease

PMHx of previous breast lumps, pain or nipple discharge.

Note association with pregnancy, postpartum and lactation.

Investigate drug intake including OTC preparations and illicit drugs especially opioids.

Question 6

Key examination

Answer 6

Careful examination of the breast, particularly the nipples and ductal area

Examine associated lymph node regions

Question 7

Key investigations

Answer 7

pregnancy test

swab of any purulent discharge

cytology of discharge

prolactin level

excision biopsy of discharging duct area.

Discuss imaging (e.g. mammography, ultrasound, galactography) with consultant

Question 8

Diagnostic tips

Answer 8

If the discharge is bilateral then serious breast disease is unlikely—consider mammary dysplasia and pregnancy.

Bloodstained discharge is caused by intraduct papilloma (commonest) and intraduct carcinoma.

Green-grey discharge: consider mammary dysplasia and mammary duct ectasia.

Yellow discharge: intraduct carcinoma (serous), mammary dysplasia and pus from a breast abscess.

Milky-white discharge (galactorrhoea): lactation, lactation cysts, hyperprolactinaemia and drugs.

Consider malignancy in women with a new breast discharge (>40 years) and bloody discharge.

Nipple discharge in a male is always abnormal.

Question 9

Characteristics

Answer 9

This may be intermittent from one or both nipples.

A common reason is physiological, is usu. part of a normal hormonal process.

Discharge can be induced by quadrant compression.

bloodstained

• –intraduct papilloma (commonest)
• –intraduct carcinoma
• –mammary dysplasia

green-grey

• –mammary dysplasia
• –mammary duct ectasia

yellow

• –mammary dysplasia (serous)
• –breast abscess (pus)

milky white (galactorrhoea)

• –lactation cysts
• –lactation
• –hyperprolactinaemia
• –drugs (e.g. chlorpromazine)