Gynecology Book

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Nipple Discharge

Aka: Nipple Discharge, Breast Discharge
  1. See Also
    1. Galactorrhea
    2. Breast Mass
    3. Mastalgia
  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. Types: Discharge associated with Cancer
    1. Watery: 45%
    2. Sanguineous: 25%
    3. Serosanguinous: 12%
    4. Serous: 6%
  4. Exam
    1. See Clinical Breast Exam
    2. Pressure point exam (in spontaneous Nipple Discharge evaluation)
      1. Elicit discharge from periphery toward nipple
      2. Distribute pressure evenly from each number of clock
      3. Document location that elicits Nipple Discharge
  5. Findings
    1. Galactorrhea
      1. Milky, bilateral discharge
      2. Hormonal and does not reflect intrinsic Breast disease
      3. See Galactorrhea
    2. Physiologic discharge
      1. Bilateral, multi-ductal, non-spontaneous, non-bloody Nipple Discharge
      2. Provoked by nipple stimulation or Breast compression
      3. Physiologic discharge may be yellow or gray, or even green or black
      4. Nipple Discharge may persist normally for up to 1 year after Breast Feeding discontinued (or delivery)
    3. Pathologic discharge
      1. Spontaneous, unilateral from a single duct opening at the nipple
      2. Discharge may be bloody, serous, serosanguinous or watery
  6. Labs: Galactorrhea
    1. See Galactorrhea
    2. Urine Pregnancy Test (key, first-line study)
    3. Thyroid Stimulating Hormone
    4. Serum Prolactin
  7. Diagnostics
    1. Cytology (of Breast Discharge)
      1. NOT recommended due to high False Negative Rate
    2. Breast Discharge culture and sensitivity
      1. NOT recommended (not useful)
      2. Usually grows skin contaminant
  8. Imaging
    1. Mammogram
      1. First-line study for pathologic Nipple Discharge in age >30 years
        1. Also obtain breast Ultrasound for women >40 years old
      2. Low Test Sensitivity (10-25%)
        1. Small subareolar masses without microcalcifications
    2. Breast Ultrasound
      1. First-line study for pathologic Nipple Discharge in age <30 years
      2. Adjunct to Mammogram in women age >40 years
      3. Variable Test Sensitivity and Specificity
    3. Galactogram (Ductogram or Ductography)
      1. Contrast-enhanced mamogram
      2. Inject Radiocontrast Material into involved duct
      3. May be used to isolate intraductal pathology for surgery when Mammogram and Ultrasound negative
      4. Technically challenging and limited availability
  9. 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%)
  10. Evaluation
    1. Breast Mass present
      1. See Breast Mass for evaluation and management
    2. Galactorrhea
      1. Obtain Pregnancy Test, and if negative, TSH and Serum Prolactin levels
      2. See Galactorrhea for evaluation and management
    3. Physiologic Nipple Discharge (Non-Spontaneous bilateral, non-bloody discharge with Breast manipulation)
      1. Normal, physiologic Breast secretions
      2. Eliminate Breast compression, nipple stimulation that increases Nipple Discharge expression
      3. Re-examination in 3 months
      4. If age >40 years, obtain diagnostic Mammogram and breast Ultrasound (if not done in prior 6 months)
    4. Pathologic Nipple Discharge (Unilateral, single duct spontaneous Nipple Discharge)
      1. Breast Cancer risk: 10%
      2. Obtain breast Ultrasound and Mammogram
        1. May forego Mammogram if age <30 years, Ultrasound definitive, and no increased Breast Cancer risk
        2. Precaution: Normal Mammogram and breast Ultrasound does not exclude pathology
      3. Management for BI-RADS 1 to 3
        1. Surgically excise involved ductal system and send for pathology
        2. Duct localization may utilize dye injection, ductography or MRI
          1. Sauter (2004) Surgery 136:780-5 [PubMed]
      4. Management for BI-RADS 4 to 5
        1. Tissue biopsy
  11. References
    1. Gulay (1994) J Am Coll Surg 178(5): 471-4 [PubMed]
    2. Salzman (2019) Am Fam Physician 99(8): 505-14 [PubMed]

nipple discharge (C0149741)

Definition (NCI_NCI-GLOSS) Fluid that is not milk coming from the nipple.
Concepts Sign or Symptom (T184)
ICD10 N64.52
SnomedCT 54302000, 139444000, 139447007, 155960006, 290107000, 162167000, 162164007
LNC LP7442-9, MTHU007943
English BREAST DISCHARGE, Nipple discharge, Nipple discharge NOS, Obs nipple discharge, nipple discharge (symptom), Discharging nipple, breast discharge, breast discharges, discharge from nipple, nipple discharge (diagnosis), discharge of nipple, Nipple discharge NOS (finding), Observation of nipple discharge (finding), Breast discharge, Discharge from nipple, Nipple discharge symptom, Observation of nipple discharge, Discharge from nipple (disorder), Nipple discharge symptom (finding), breast; discharge, discharge; breast, discharge; nipple, nipple; discharge, Nipple Discharge, nipple discharge
Italian Secrezione mammaria, Secrezione del capezzolo, Secrezione dal capezzolo
Dutch tepeluitvloed, uitvloed tepel, afscheiding; mamma, afscheiding; tepel, mamma; afscheiding, tepel; afscheiding, borstuitvloed
French Ecoulement du mamelon, Mamelon avec écoulement, ECOULEMENT MAMMAIRE, Ecoulement mammaire
German Brustwarzenabsonderung, sekretierende Brustwarze, ABSONDERUNG BRUSTDRUESE, Brustdruesenabsonderung
Portuguese Corrimento mamilar, Mamilo com corrimento, SECRECAO MAMARIA, Corrimento mamário
Spanish Pezón secretor, Secreción del pezón, PEZON, EXUDADO, derrame por el pezón (trastorno), secreción por el pezón (trastorno), secreción por el pezón, derrame por el pezón, derrame mamario, secreción del pezón, SAI, Nipple discharge NOS, secreción del pezón, SAI (hallazgo), síntoma de secreción del pezón (hallazgo), síntoma de secreción del pezón, Secreción mamaria
Japanese 乳頭分泌, 乳房分泌, ニュウトウブンピツ, ニュウトウブンビツ, ニュウボウブンピ, ニュウボウブンピツ, ニュウトウブンピ
Czech Výtok z prsu, Výtok z bradavky
Hungarian Emlő váladékozás, Váladékozó emlőbimbó, Emlőbimbó váladékozás
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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