Nipple Discharge

Key Features

• Common causes in the nonlactating breast

  • Duct ectasia

  • Intraductal papilloma

  • Carcinoma

• Characteristics of nipple discharge and their clinical significance in nonpregnant, nonlactating women

  • Serous: Most likely benign fibrocystic condition, ie, duct ectasia

  • Bloody: More likely neoplastic–papilloma, carcinoma

  • Associated mass: More likely neoplastic

  • Unilateral: Either neoplastic or non-neoplastic

  • Bilateral: Most likely non-neoplastic

  • Single duct: More likely neoplastic

  • Multiple ducts: More likely fibrocystic condition

  • Milky: Endocrine disorders, medications

  • Spontaneous: Either neoplastic or non-neoplastic

  • Produced by pressure at single site: Either neoplastic or non-neoplastic

  • Persistent: Either neoplastic or non-neoplastic

  • Intermittent: Either neoplastic or non-neoplastic

  • Related to menses: More likely fibrocystic condition

  • Premenopausal: More likely fibrocystic condition

  • Taking hormones: More likely fibrocystic condition

Clinical Findings

• Unilateral, spontaneous serous, or serosanguineous discharge from a single duct caused by

  • Ectatic duct

  • Intraductal papilloma (usually)

  • Intraductal cancer (rarely)

• Bloody discharge suggests cancer but is more often due to benign papilloma in duct

• Fibrocystic condition in premenopausal women characterized by spontaneous, brown or green discharge

  • From multiple ducts

  • Unilateral or bilateral

  • Most marked just before menstruation

• Milky discharge from multiple ducts occurs from

  • Hyperprolactinemia

  • Certain drugs (antipsychotics)

• A clear, serous, or milky discharge from single or multiple ducts

  • Can occur with oral contraceptives or estrogen replacement therapy

  • Disappears when patient stops taking the medication

  • More evident just before menstruation

• Purulent discharge may originate in a subareolar abscess

Diagnosis

• If unilateral discharge from single duct, involved duct can be identified by pressure at different sites around nipple at margin of areola

• Check serum prolactin and thyroid-stimulating hormone levels if discharge is milky

• Mammography and ultrasound may be helpful if localization of lesion is not possible

• Differential diagnosis

  • Galactorrhea (eg, pregnancy, postpartum, hyperprolactinemia)

  • Mammary duct ectasia

  • Intraductal papilloma

  • Breast cancer

  • Oral contraceptives or estrogen replacement therapy

  • Fibrocystic condition

  • Subareolar abscess

Treatment

• Any mass or, in the case of duct ectasia or intraductal papilloma, any involved duct should be excised

• Abscesses require drainage or removal along with the related lactiferous sinus

• When localization is not possible, no mass is palpable, and discharge is nonbloody, the patient should be reexamined every 3 or 4 mo for 1 yr, and mammography and ultrasound are performed