evaluation of patient with nipple discharge

Last reviewed 01/2018

evaluation of patients with nipple discharge

A detailed history combined with a careful physical examination usually helps in an accurate differential diagnosis.

History should address the following:

  • colour of discharge
    • blood stained discharge is always abnormal and usually suggestive of serious underlying pathology
    • presence of galactorrhoea is likely to indicate an endocrinopathy

  • unilateral or bilateral
    • bilateral discharge is usually caused by systemic conditions e.g. - physiological (such as lactational), endocrine (such as prolactinoma, hypothyroidism) or iatrogenic (such as medications)
    • unilateral discharge indicates a local cause e.g - ductal papilloma, breast cyst, or ductal carcinoma

  • associated symptoms   
    • palpable breast lump or new-onset nipple inversion - suspect breast malignancy
    • local or systemic signs of infection in nipple discharge may be caused by an abscess
    • weight gain or cold intolerance may indicate that the nipple discharge is secondary to hypothyroididsm

  • medications
    • ask about the use of medications which might cause nipple discharge

  • other patient factors
    • age of patient
      • in premenopausal women and girls – most likely to be physiological, lactational, medication related, or secondary to a ductal papilloma
      • perimenopausal and postmenopausal - more likely due to a papilloma, duct ectasia, or breast cancer
      • discharge in male patients is abnormal

Examination of patient:

  • inspection
    • look for signs suggesting an underlying breast cancer e.g. - skin tethering or asymmetry of the breasts,  peau d’orange 
    • erythematous skin may be seen in mastitis or breast abscess and in rare cases can be due do inflammatory breast cancer (specially in the absence of other signs of sepsis)
    • weeping of the skin – seen in atopic eczema or contact dermatitis from detergents, cellulitis, Candida infections, and mastitis

  • palpation
    • examine of all four quadrants of the breast, axillary tail, axillae and supraclavicular regions to identify any masses or lymphadenopathy
    • observe the central breast below the nipples specially to identify the cause for discharge
    • palpate around the areola circumferentially to see if the discharge can be expressed (1)

Reference: