Continuing Education Activity

Nipple discharge is fluid that leaks from one or both nipples of non-pregnant and non-breastfeeding women. Nipple discharge can at times be a complex diagnostic challenge for clinicians since it can be completely benign and due to excessive nipple stimulation, or can be a manifestation of a wide variety of diseases. With heightened public awareness of breast cancer, an increasing number of women are asking their health care providers about nipple discharge. Thus, clinicians must be knowledgeable regarding the best practices for evaluating nipple discharge. This activity reviews the causes of nipple discharge and highlights the role of the interprofessional team in its workup and management.

Objectives:

• Identify the etiology of nipple discharge.
• Describe the presentation of a patient with nipple discharge.
• Explain the workup for a patient with nipple discharge.
• Describe how an optimally functioning interprofessional team would coordinate care to enhance outcomes for patients with nipple discharge and their families.

Introduction

Any fluid that leaks from one or both nipples of a non-pregnant and non-breastfeeding breast is referred to as nipple discharge. Nipple discharge is a complex diagnostic challenge for the clinician as it can occur normally or be a manifestation of a wide variety of diseases. Each human breast has 15 to 20 milk ducts. Nipple discharge can originate from one or more of these milk ducts.

The most important consideration in a patient with nipple discharge for both the patient and the physician is the possible association of this condition with underlying breast cancer. With the increased public awareness of breast cancer, an increasing number of women are asking their health care providers about nipple discharge. Thus, a clinician must be aware and knowledgeable in evaluating nipple discharge. Nipple discharge is not an uncommon complaint in the emergency department and can be benign (physiologic discharge) or a sign of a pathologic process.[1]

Nipple discharge is normal during the last few weeks of pregnancy, after childbirth, and during the breastfeeding period. It can also be normal in women who are not pregnant and are not breastfeeding, especially during reproductive years. Certain manipulations of the breasts, such as fondling, sucking, or massaging can stimulate milk ducts to secrete fluid. Stress also has been shown to cause nipple discharge.[1] All postmenopausal nipple discharge, however, is significant and requires further evaluation. Nipple discharge in men is always abnormal and also must prompt an evaluation.[2][3]

Etiology

The majority of all nipple discharges are benign in etiology (97%).[1][2][4][3]

Causes of Physiologic Nipple Discharge

1. Pregnancy
2. Lactation
3. Postpartum galactorrhea may last up to two years after delivery
4. After spontaneous or intentional termination of pregnancy
5. Fibrocystic changes of the breast
6. Hormonal fluctuations associated with the menstrual cycle
7. Duct ectasia
8. Intraductal papilloma

Causes of Pathologic Nipple Discharge

1. Infection (periductal mastitis)
2. Breast abscess
3. Neoplastic process of the breasts (e.g., intraductal carcinoma, Paget disease of breast)
4. Pituitary tumor/prolactinoma
5. Thoracic/breast trauma
6. Systemic disease/endocrinopathies that elevate prolactin level (e.g., hypothyroidism, disorders of the pituitary gland or hypothalamus, chronic kidney or liver disorders)
7. A side effect of medications that inhibit dopamine secretion (e.g., opioids, oral contraceptives, antihypertensives (methyldopa, reserpine, verapamil), antidepressants, and antipsychotics)

Epidemiology

Nipple discharge is the third most common breast complaint after breast pain and breast mass. Fifty percent to 80% of women in their reproductive years have nipple discharge, and 6.8% of these are referred to a breast surgeon. Most nipple discharge is benign in origin (97%).[5]

History and Physical

The clinical history is most helpful in distinguishing benign from suspicious or pathologic nipple discharge. The patient's age is very important, as women greater than 40 years of age are at higher risk of having pathologic discharge. Postmenopausal women with nipple discharge are rarely benign.

History of present illness should include the onset of discharge, association with the menstrual cycle, persistence, and the character and color of the discharge. A patient's reproductive history is important (e.g., the age at menarche, age at menopause, and history of pregnancies including age at first full-term pregnancy). Other relevant histories, including a history of any breast problems, including breast biopsies, and surgical history (e.g., hysterectomy and whether ovaries were removed) are required for diagnosis. In premenopausal women, obtain the pregnancies/births history, history of breastfeeding, and the use of oral contraception or hormone replacement therapy (HRT). Family history should contain information about cancers, especially breast/ovaries, and the menopausal status of close relatives. Medications history is of paramount importance, as many medications can cause nipple discharge as a side effect. One must not miss the presence of fever (mastitis or breast abscess), symptoms of hypothyroidism (weight gain, cold intolerance, constipation, amenorrhea), symptoms of liver disease (ascites, jaundice), and symptoms of a pituitary tumor (visual changes, amenorrhea, headache) to narrow down the differential diagnosis of nipple discharge.

The patient should be examined for the presence of any breast masses, asymmetry, and skin changes. After the inspection, palpation should include all four quadrants of each breast and bilateral axillae, supra- and infraclavicular areas to look for masses, swelling, tenderness, and lymphadenopathy. If no spontaneous discharge is visible, the examiner should attempt to extract the discharge by applying even pressure from the periphery toward the nipples (so-called, pressure point exam).

Physiologic discharge is usually bilateral, with clear fluid, involves multiple ducts, and is non-sticky. Pathologic discharge is usually unilateral, spontaneous, varied in appearance, and depending on the cause, involves a single duct. Abnormal discharge is frequently associated with other abnormalities, such as a mass, swelling, redness, dimpled skin, or retracted nipple.[2][4]

Evaluation

The primary goal of evaluation of the nipple discharge in a general outpatient setting or the emergency department is to distinguish patients with benign discharge from those with underlying breast cancer, infection/abscess, or those patients who are at high risk of developing pathologic processes. Those patients, whose age, history, and physical examination suggest the benign cause of their discharge, may be reassured and discharged with outpatient follow-up at their primary care provider's office. However, in patients at high risk for a pathologic process as a cause of their discharge or with worrisome history and physical examination, urgent follow-up with a breast surgeon must be sought.[2][4]

The first step in the evaluation of breast discharge is to rule out whether the discharge is physiological or pathological. Physiological discharge is bilateral and is clear or milky. Pathological discharge is always unilateral and may be bloody. It is hence important to note the color of discharge, whether it occurs spontaneously or occurs with stimulation (which is physiological). Also, associated symptoms are interpreted to make the final diagnosis. 

For patients with physiological discharge, TSH levels, and prolactin levels are measured to rule out systemic causes of nipple discharge. For patients lesser than 40 years of age, routine observation is required. For patients greater than 40 years of age, mammography is indicated. In patients with pathological discharge, mammography and/or ultrasound are performed. If abnormal, a breast biopsy is performed. If normal, then breast MRI, or surgical excision of the lump (if an associated lump is present) is done. Fluid cytology can also be acquired to study the malignant cells in patients with blood discharge, where breast cancer is suspected.[6][4]

In case of a suspected or obvious breast abscess when emergent ultrasound of the breast and a general surgery consultation are needed in the emergency department. Depending on the results of the breast ultrasound and evaluation of the general surgery consultants, the patient may or may not be taken to the operating room for incision and drainage of an abscess. Incision and drainage of a breast abscess in the emergency department are discouraged due to the high pain sensitivity and aesthetic significance of the area, especially when an abscess involves the areola/nipple area. Therefore, appropriate anesthesia is needed, possibly in the operating room, to minimize pain and suffering in a patient, as well as aesthetic considerations.

Treatment / Management

The treatment of breast discharge depends on the etiology. A physiological discharge does not require any treatment. Systemic causes of nipple discharge require specific medications. Benign causes of breast discharge like duct ectasia requires microdochectomy (removal of one duct) or total duct excision (removal of all ducts). Duct papillomas that produce unilateral bloody discharge require microdochectomy. Breast cancer-producing bloody nipple discharge requires surgery and/or chemotherapy or radiation depending on the staging of the disease. Purulent discharge is treated with appropriate antibiotics, but abscesses need incision and drainage and wall biopsy of the abscess.[7][8][9]

Differential Diagnosis

• Intraductal papilloma
• Duct ectasia
• Fibrocystic changes and mastitis
• Intraductal carcinoma
• Paget disease of the nipple

Prognosis

Most nipple discharge is due to an intraductal papilloma and these patients have an excellent outcome when the lesion is excised.

Deterrence and Patient Education

The nurse, the clinician, and the pharmacist play a pivotal role in educating patients with nipple discharge and their families about their condition. The interprofessional team should ensure that patients are given the necessary information about their condition and the available treatment options. A clear and open discussion about the goals of their care plan and any available alternatives. The nurse should provide patients with written information leaflets about their condition and refer them, if available, to educational websites that will enhance their understanding of their disease.

Enhancing Healthcare Team Outcomes

Nipple discharge is best managed by an interprofessional team, including nurse practitioners. However, it is important to be aware that not all nipple discharge is benign. In some cases, a mass may be present, and further workup to rule out malignancy is recommended. The nurse has a crucial role in addressing the concerns of patients with women discharge, as this diagnosis could carry a tremendous negative emotional impact on patients and their families. The nurse assists the clinician in counseling these women and responding to their concerns throughout the journey of their management. The nurse carefully observes the characteristics of the nipple discharge and makes sure to document the findings in the patient's medical records. Breast care and radiologic specialty trained nurses are often involved in the coordination of care. The nurse should report any untoward changes in the vital signs of the patient to the clinician. The nurse should communicate with other members of the interprofessional team to ensure the optimal standard of care to their patients. [Level 5]