Breast Tenderness Flashcards
What are the causes of breast tenderness and pain
Breast engorgement
Mastitis
Breast abscess
Mastodynia
Trauma
Pregnancy
Fibrocystic disease.
Malignancy.
Stretching of Coopers ligaments.
Diabetic mastopathy.
Define breast engorgement
breasts become large, hard, uncomfortable and painful ± fever up to 39, often very early e.g. 2nd day postpartum, usually bilateral BUT there will not be erythema or discharge
What is the management for breast engorgement
CONTINUE breastfeeding
Manual/electric expression
Firm support
Cabbage leaves
Ice bags
Define mastitis
A blocked duct obstructs the flow of milk and distends the alveoli, if pressure persists the milk extravasates into the perilobular tissue → inflammation of the breast with or without infection
What are the causes of mastitis
Either lactational or non-lactational
Infectious:
- Staphylococcus
- Coagulase negative staphylococci e.g. epidermis
- MRSA
Non-infectious:
- Duct-ectasia
- Foreign material e.g. nipple piercing, implant, silicone
- Granulomatous mastitis
What are the risk factors for mastitis
Lactational: poor breastfeeding technique, milk stasis
Female
>30
Nipple injuries
Previous mastitis/abscess
Shaving/plucking areola hair
Foreign bodies
What are the symptoms of mastitis
Often develops later than engorgement (3rd-4th week), usually unilateral
Breast:
- Pain - Usually sharp, shooting, or throbbing breast pain, especially with breastfeeding, may indicate mastitis
- Warmth
- Tenderness
- Firmness
- Swelling
- Erythema
Fever
Lactation issues: Reduced milk outflow (milk stasis) - involves more peripheral wedge-shaped areas.
Systemic: fatigue, myalgia, flu-like symptoms
± nipple discharge, inversion/retraction, lymphadenopathy, skin lesions
What are the signs of mastitis on examination
Obs: pyrexia, tachycardia
Breast: Wedge-shaped area of tenderness, warmth, swelling, erythema, and firmness
Tender axillary lymph nodes
± nipple discharge, retraction/inversion
What investigations should be done for mastitis
Usually clinical diagnosis
1. Examine the breast
2. Record the temperature
3. Consider pregnancy test if unexpected e.g. in adolescent
4. Refer for USS of the breast
Bedside: urine dip, pregnancy test, nipple discharge for MC&S, milk for MC&S
Bloods: Blood cultures, FBC
Other:
- USS (abscess may appear as well-circumscribed, macrolobulated, irregular, or ill-defined echo-poor compound cystic lesion
- needle aspiration for cytology: ?Abscess
- Mammography: ?cancer
What is the management for lactational mastitis
Supportive:
- Paracetamol or ibuprofen
- Breastfeeding should continue frequently (e.g., breastfeeding 8-12 times per day)
- Breast pumping on the affected side if indicated and/or massage, if tolerated, may also be used
- Counselling on importance of milk expression
- Increase fluid intake and to try warm/cold compress
- Massage towards the nipple
Severe/prolonged/systemic signs: empirical Abx e.g. flucloxacillin
MRSA confirmed: clindamycin, trimethoprim (non beta-lactam)
What is the management for nipple candidiasis
Topical antifungal e.g. nystatin or miconazole
What is the management for non-lactational mastitis
MRSA excluded: empiric Abx e.g. flucloxacillin
MRSA confirmed: Non-beta-lactam antibiotic e.g. clindamycin, trimethoprim, vancomycin
What is the management for breast abscesses
MRSA excluded:
- Needle aspiration and send for culture
- Oral/IV ABx
- Supportive care
MRSA confirmed:
Non-beta-lactam antibiotic e.g. clindamycin, trimethoprim, vancomycin
- Needle aspiration and send for culture
- Oral/IV ABx
- Supportive care
What are the complications of needle aspiration from the breast
The risk of failure for needle aspiration is greater with abscesses >5 cm in diameter.
Breast tissue destruction → functional mastectomy
Injury to the breast bud in pre-pubertal children → Breast hypoplasia
Post-operative scar
