Nipple Discharge
Differential Diagnosis
Common Diagnoses
- Pregnancy
- Duct Papilloma
- Duct Ectasia
- Acute Mastitis/Breast Abscess
- Areolar Abscess (Infected Gland of Montgomery)
Occasional Diagnoses
- Oral Contraceptives
- Intraduct Carcinoma
- Neonatal and Peripubertal Galactorrhoea (Also Post-Lactation)
- Hyperprolactinaemia (Drugs, Prolactinoma, Hypothyroidism)
- Duct Epithelial Proliferation
- Galactocoele
Rare Diagnoses
- Periductal (Plasma Cell) Mastitis
- Mechanical Stimulation
- Invasive Carcinoma
- Tuberculous Abscess
- Mamillary Duct Fistula
- Paget’s Disease of Nipple
- Comedo Mastitis
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Pregnancy | Papilloma | Ectasia | Mastitis | Areolar Abscess | |
|---|---|---|---|---|---|
| Bloodstained | No | Yes | Possible | Possible | Possible |
| Multicoloured/Cheesy | No | No | Yes | No | No |
| Purulent | No | No | No | Yes | Yes |
| Hot Tender Segment | No | No | No | Yes | Yes |
| Bilateral | Yes | No | Possible | No | No |
Possible Investigations
Likely:None (referral for specialist assessment in suspicious cases)
Possible: Pregnancy test, prolactin level, TFT
Small Print:Swab of purulent discharge.
- Pregnancy test if pregnancy suspected
- Swab purulent discharge: May help guide antibiotic therapy
- Prolactin level and TFT: To check for hyperprolactinaemia or hypothyroidism in galactorrhoea.
- Excision biopsy will be performed if a suspicious lump is palpable. In cases of doubt, mammography may help; surgical exploration may also be undertaken if pressure on an area of one breast consistently elicits discharge.
Top Tips
- Women presenting with breast discharge are likely to be afraid there may be an underlying cancer. To ‘reassure’ properly, make sure you address this anxiety.
- If the discharge is bilateral, then serious breast disease is highly unlikely.
- In a woman of child-bearing age with bilateral serous discharge, enquire specifically about pregnancy – this possibility may be deliberately concealed or genuinely overlooked by the patient.
- If a pre-menopausal woman is amenorrhoeic with bilateral discharge and pregnancy has been excluded, remember the possibility of hyperprolactinaemia.
Red Flags
- Refer urgently any patient aged 50 or more with a unilateral discharge, retraction or other nipple symptoms of concern.
- If a lump is palpable, or pressure on a certain area of the breast consistently produces the discharge, refer for probable excision biopsy.
- Bright red blood from one nipple is usually caused by duct papilloma or ectasia – but can be caused by carcinoma and therefore requires prompt referral.
- Nipple discharge in a male is always abnormal, except occasionally in pubertal boys. Investigate or refer as appropriate