Nipple 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]