Red flag symptoms - Nipple discharge

Dr Mehul Mathukia highlights reasons for concern with this presentation.

Examine the nipple, including the colour and nature of the discharge (Photograph: SPL)
Examine the nipple, including the colour and nature of the discharge (Photograph: SPL)
Nipple discharge is a common complaint in women, particularly in the reproductive years.

Most cases of nipple discharge are due to normal benign conditions and are usually hormone related.

Nipple discharge can be elicited in approximately 20 per cent of women just by squeezing the nipple.

Red flag symptoms
  • Bloody discharge
  • Unilateral discharge
  • Spontaneous discharge
  • Hard, irregular palpable mass
  • Age > 40
  • Male

History
Salient points in the history include whether the discharge is unilateral or bilateral, and the colour and nature of the discharge - whether it is milky or purulent. Also relevant in the history is whether the discharge is spontaneous, how long it has been present and whether a lump or pain is present in the breast.

Associated symptoms such as a fever may suggest an abscess.

Amenorrhoea, infertility or visual disturbances may suggest an underlying pituitary tumour.

Other causes of hyperprolactinaemia including a history of renal failure, underlying thyroid disease and liver disorders should also be explored.

Drugs including oral contraceptives, H2 antagonists (eg ranitidine), opioids and dopamine antagonists (eg tricyclics and phenothiazines) can also cause prolactin release.

Examination
Physical examination should focus on the breasts.

On inspection, one should look for symmetry, dimpling of the skin, erythema, swelling, colour changes in the nipple and skin, and crusting, ulceration or retraction of the nipple. One should palpate for masses and lymph nodes in the axillary and supraclavicular region.

One may wish to consider stimulating the area around the nipple to elicit discharge, if no spontaneous discharge is present.

The use of a light may help in distinguishing between uniductal and or multiductal discharge.

Investigations
Investigations will be directly guided by the clinician's assessment. Blood tests including TFTs and prolactin may suggest an endocrine cause. The discharge may be sent for cytology.

If a lump is present, an ultrasound or mammography is required. Abnormal results may require an ultrasound-guided biopsy.

Treatment is based on the underlying cause of the nipple discharge.

If the cause is benign but persistent and annoying for the patient, a nipple flap duct resection can eliminate the discharge and relieve anxiety for the patient.

  • Dr Mathukia is a GP principal in Ilford, Essex
Possible causes
  • Intraductal papilloma (benign)
  • Breast cancer
  • Hyperprolactinaemia
  • Mammary duct ectasia
  • Fibrocystic changes
  • Abscess or infection.

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