Chapter 57

Nipple discharge affects 5% to 30% of women during their lifetime. Surgery is rarely indicated. Many benign conditions cause nipple discharge, including duct ectasia, cystic disease, papillomas, infection, and abnormal production of prolactin. In addition, many medications can produce discharge. Discharges are usually categorized as physiologic or pathologic, depending on their color, frequency, and the involvement of single or multiple ducts. Those discharges that are bilateral, creamy or greenish in color, draining from multiple ducts, nonspontaneous, and associated with an otherwise normal physical exam and mammogram are rarely due to cancer or papillomas and do not require surgery except rarely for relief of symptoms. Clinical characteristics that suggest a pathologic discharge are unilateral discharge through a single duct; the presence of a bloody, clear, or serous discharge; discharge that is spontaneous; and those associated with a mass. Pathologic discharges usually require surgery to rule out a malignant cause, although cancer as a cause of nipple discharge is unusual.1-3 In a series of 204 patients presenting to a multidisciplinary group with nipple discharge, only 7 (3%) were found to have cancer or 9% of those ultimately referred for surgery.2 In a group of 82 patients referred to a surgical clinic with pathologic nipple discharge (spontaneous red or serous discharge from a single duct), 4 were found to have cancer (5%). Advanced age has been seen to be a predictor of cancer in women with nipple discharge.1,2

A patient presenting with a pathologic nipple discharge for evaluation should have a mammogram and physical examination.

Physical Examination

A physical exam should include the usual palpation of the breast as well as looking for trigger points that elicit the discharge. This trigger point is often used to decide on location for the circumareolar incision. The nipple is carefully inspected for adenomas in the nipple as well as excoriations or skin changes that can lead to blood on the surface of the nipple. Excoriations from trauma, eczema, fungal rashes, and Paget disease can lead to blood staining of the bra, which patients can mistake for a nipple discharge.

The nipple discharge should be elicited to confirm the color, volume, and whether a single or multiple ducts are involved. The color should be distinguished by placing it on a white surface like gauze as the green-black discharge of duct ectasia is often mistaken for blood and these 2 discharges are treated differently. Yellow or green discharge from multiple ducts is usually a sign of duct ectasia and rarely requires surgery. The absence of blood on a guaiac card does not eliminate the possibility of a pathologic discharge,4 but its strong presence demands further evaluation. Any palpable mass should be needle biopsied. A nearby cyst can discharge into the nipple causing a serous discharge, and aspiration can halt the discharge. Similarly, infectious processes may discharge into the nipple and signs of infection should be treated ...

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