Nipple Discharge

1. See Also
   1. Galactorrhea
2. History
   1. Pregnancy and Lactation history
      1. Galactorrhea is normal during pregnancy and for up to one year after cessation of Lactation
   2. Does the Nipple Discharge occur spontaneously?
      1. "Does discharge stain underclothing or bed clothing?"
   3. What Color is the Nipple Discharge?
      1. Bloody Nipple Discharge is NOT synonymous with cancer
      2. However bloody Nipple Discharge carries a higher risk of cancer
   4. Is more than one duct involved?
   5. Is the Nipple Discharge Unilateral or Bilateral?
   6. How long has the Nipple Discharge been present?
   7. Is the Nipple Discharge persistent?
3. Evaluation
   1. Non-Spontaneous Discharge (with Breast manipulation)
      1. Normal Breast Secretions
   2. Spontaneous Nipple Discharge (10% Breast Cancer)
      1. Unilateral Nipple Discharge
         1. Multiple Duct
            1. Probable benign Breast pathology
            2. Follow-up exam only
         2. Single Duct
            1. Probable Breast pathology or Breast Cancer
            2. Normal Mammogram and breast Ultrasound does not exclude pathology
            3. Surgically excise involved ductal system and send for pathology
               1. Involved ductal system can be identified with dye injection into duct with discharge
               2. Sauter (2004) Surgery 136:780-5 [PubMed]
      2. Bilateral Nipple Discharge
         1. Galactorrhea
            1. Probable systemic cause (Endocrine cause)
            2. See Galactorrhea
         2. Non-Galactorrhea
            1. See Unilateral Nipple Discharge above
4. Types: Discharge associated with Cancer
   1. Watery: 45%
   2. Sanguineous: 25%
   3. Serosanguinous: 12%
   4. Serous: 6%
5. Causes
   1. Galactorrhea
      1. See Hyperprolactinemia Causes
      2. See Medication Causes of Hyperprolactinemia
   2. Bloody Nipple Discharge Etiologies
      1. Intraductal Papilloma (most common)
      2. Duct ectasia (Benign Breast duct tortuosity)
      3. Breast Cancer (represents <3%)
6. Labs: Bilateral Nipple Discharge
   1. See Galactorrhea
   2. Urine Pregnancy Test
   3. Thyroid Stimulating Hormone
   4. Serum Prolactin
7. Evaluation: Spontaneous Nipple Discharge
   1. Pressure point exam
      1. Elicit discharge from periphery toward nipple
      2. Distribute pressure evenly from each number of clock
      3. Document location that elicits Nipple Discharge
   2. Cytology
   3. Galactogram (Ductogram)
      1. Inject Radiocontrast Material into involved duct
   4. Culture and sensitivity are not useful
      1. Usually grows skin contaminant
8. References
   1. Gulay (1994) J Am Coll Surg 178(5): 471-4 [PubMed]