Key distinguishing features of the most common diagnoses
|Hot Tender Segment||No||No||No||Yes||Yes|
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.
- 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.
- 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