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Nipple Discharge

Nipple discharge is not an uncommon symptom but when it occurs, it is distressing. Ninety per cent are usually due to benign conditions.

Types of Nipple Discharge

Clear serous discharge, may be physiological and is seen usually in parous women or it may be associated with duct papilloma or with fibrocystic disease and rarely in Carcinoma.

Milk discharges are seen in patients with lactation, hypothyroidism, pituitary tumour and Cushing’s disease. Milk discharge is otherwise known as Galactorrhoea.

Blood stained discharges are seen in patients with duct ectasia, duct papilloma or Carcinoma.

Black or greenish discharges are seen in patients with duct ectasia.

Pultaceous discharge that is white, yellow or grey are seen in duct ectasia.

Pus or purulent discharges are seen in infection.

Examination of patient with nipple discharge is done after the nipple is cleaned and then squeezed by firm pressure by milking the breast tissue around the areola towards the nipple. The site and nature of the discharge is noted and also the number of duct involved. The discharge is taken on a glass slide for occult blood testing and cytology.

Examination of the breast and axilla has to be done, to detect any lump or thickening. All patients would require an ultrasound examination. Women above the age of 35, a mammogram should be considered. If the discharge is negative for cytology and occult blood, and ultrasound and mammogram are normal and the discharges from a single duct, a conservative approach is indicated and a follow-up later is done. Women above the age of 45 would need a closer observation.

Patients with intraductal papilloma usually present as a single duct discharge and may have blood or occult blood. Ultrasound may reveal a dilated duct with papilloma in some patients. Such patients will require a Microdochectomy operation.

Duct Ectasia. Patients here present with thick discharge which may be whitish, yellowish, greenish or a black discharge. Multiple ducts may be involved. The nipple may have a slit like retraction. The common age incidence is around 50 years. Surgery is indicated if discharge is persistent or troublesome.

Periductal Mastitis. These patients have recurrent episodes of periareolar inflammation. Smokers have a higher incidence. It is associated with periareolar abscesses, mammary fistula. Nipple discharge if present is purulent and smelly. Swabs should be taken from the discharge for culture & sensitivity. The antibiotic treatment and drainage of abscess if required.

Carcinoma. If the nipple discharge is blood stained with no clinically palpable lump is invariably a ductal carcinoma in situ or ductal papilloma. This will require a surgical procedure.

Bloody discharge in pregnancy is usually intermittent. This is due to increased vascularity of the proliferating ductal structures. If clinical examination is normal, no treatment is required.

Milky discharge from the nipple, not associated with breast feeding is called Galactorrhoea.

  1. This may be due to certain drugs (tricyclic anti-depressants, phenothiazine and verapamil).
  2. Endocrine disorders like pituitary adenoma, hypothyroidism and Cushings disease.

Persistent milky discharge with no underlying cause may respond to anti-prolactin drugs (Bromocriptine). Persistent milky discharge with no definite aetiology may require duct ligation.

Nipple discharge in men is uncommon, most cases are caused by underlying malignancy.

Article by:
Mr Mangaden Malini Sudhakhar Krishnan

Consultant General Surgeon