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Alagaratnam FRCS (Eng), FRCS (Ed) Senior Lecturer, Dept, of Surgery University of Hong Kong
Discharge From The Nipple
Summary The common causes of a discharge from the nipple and a brief outline of their management are discussed. Introduction The normal female breast secretes a small quantity of fluid which is discharged at the nipple. These small quantities of fluid are hardly ever noticed by the patient. Abnormal discharges are invariably larger amounts which usually leave stains on the patient's clothes. Another difference between physiological and pathological secretion is its colour. Normal breast secretion is colourless or slightly yellow. Abnormal secretions are more deeply yellow, milky, brown, or blood stained. Once an abnormal discharge from the nipple is diagnosed, the next consideration is to inspect both nipples closely and look for any ulceration or eczema-like lesion. Discharges due to local lesions in the nipple must be distinguished from those associated with a normal nipple. The latter are due to causes arising from the breast tissue itself. (A) Discharges associated with an abnormal nipple. The common causes of such a condition are (1) Malignant ulceration of the nipple — This is by far the most important lesion one must be aware of. Paget's disease of the nipple presents as a small area of ulceration of the nipple and areola; it is surrounded by an area of pigmentation and scaling which should not be confused with eczema. Paget's disease is always associated with an underlying duct carcinoma. In these patients, a biopsy of the ulcerated area is necessary to confirm the diagnosis and subsequent management is as for carcinoma of the breast. (2) Non malignant ulceration — This is usually seen in young females; the condition may
be unilateral or bilateral; it is due to minor recurrent trauma to the nipple, usually due to wearing tight brassieres. Occasionally such ulcerated nipples may be associated with symptoms and signs of infection in the breast. Simple measures such as cleaning the nipple with an antiseptic and applying a protective dressing, will permit healing to occur. (3) True eczema of the nipple — This again is a condition seen in young females. It invariably affects both nipples and areolae and (in the author's experience) is usually a form of contact dermatitis due to wearing brassieres made of nylon. The local application of 1% hydrocortisone cream and a change to cotton or silk clothing results in a rapid cure. (B) Discharge associated with a normal nipple. When there is no local lesion in the nipple to account for the discharge, then one must infer that it is a secretion from breast tissue. There are, however, three clinical conditions in which the abnormal discharge may be due to physiological causes. (1) Occasionally women who take oral contraceptives may be troubled by a nipple discharge which is usually serous or milky and usually bilateral. The discharge is never blood stained. Stopping the drug usually cures the complaint. (2) Nipple discharge may occur during the middle or last trimester of pregnancy; a bloody discharge may occur from both breasts and even occasionally persist during the period of lactation. Reassurance is all that is necessary and in the majority of cases the condition usually subsidies after delivery. (3) Rarely, young women with rapidly growing breasts may develop a serous discharge during the first two days of a menstrual period. Here again there is no special treatment required.
Discharge from the nipple
In all these instances, the nipple discharge is a symptom of exaggerated proliferation of the duct epithelium under the influence of hormones. They require no special treatment. Fibrocystic disease of the breast is seldom if ever associated with a nipple discharge. If the conditions listed above have been excluded, then it is important to consider next whether the nipple discharge is associated with a lump in the breast (Fig. 1). If such a lump is detected, then subsequent investigation and management will be along the lines of any patient presenting with a lump in the breast; the nipple discharge is now of secondary importance. When there is no associated lump, one would then proceed further to ascertain whether the discharge is from a single duct, or diffusedly from several ducts. This can be done by the bed side. With the patient lying comfortably on her back, digital pressure is applied with the tip of the finger along the circumference of the areola. If light pressure elicits a discharge, then the position on the nipple at which the discharge was seen is noted .Discharge from
a single duct is always pathological, and it merits further investigation in the form of a ductogram (the duct in question is cannulated with a fine cannula and an X-Ray taken after injection of a radio-opaque dye) which will outline the lumen of the duct, permitting one to confirm the presence of single or multiple duct papillomas or a papillary type of breast carcinoma. It is extremely difficult to distinguish between the last two conditions by the bed side. Cytological examination of the discharge has been done but found to be unhelpful. Haagenson has recorded a false negative rate of 31 %1. Distinction between benign and malignant papillomas can only be done after excision of the affected duct together with the related glandular tissue of the breast (Microdochectomy). The duct must be cut open and any tumour present must be examined by frozen section. Benign papillomas require no further treatment. Malignant papillomas will need further surgery as for malignant lesions of the breast. If it is ascertained by careful physical examination that the discharge is not from one particular duct but from several ducts
No lump present
Paget's disease (Treat as for breast cancer)
Minor recurrent trauma
Eczema of nipple
Localised to one duct I
From several ducts (Duct ectasia — Haagenson's operation)
Duct carcinoma (Treat as for breast cancer)
Duct papilloma (Microdochectomy)
Management of nipple discharge
Vol. 8 No. 3, March 1986
then the underlying cause is usually duct ectasia. This is a condition usually seen in older post-menopausal and in women who are near the menopause. Due to the hormonal changes occurring during this period, the ducts become dilated and filled with secretion resulting in a discharge from the nipple. Occasionally the duct contents may escape into the surrounding breast tissues and give rise to a painful swelling in the periareolar region. Treatment for this condition is by Haagenson's operation in which through an inferior circumareolar incision a block of tissue (containing the dilated ducts) immediately subjacent to the nipple is excised.
It is important to bear in mind that discharge from the nipple should not divert the practitioner's attention from examining the whole breast, axillae, supraclavicular region and abdomen. It is not uncommon to find nipple discharge occurring coincidentally with a.more peripherally located carcinoma and a delay in diagnosis can be avoided if one remembers to examine the whole breast and not be satisfied with examining only those areas related to the patient's symptoms.
Reference 1. Haagenson C.D. (1971) Diseases of the breast p. 143. H.B. Saunders, Philadelphia.
The New Zealand Family Physician
The journal of the Royal New Zealand College of General Practitioners.
Editor: Ian M St George. General Practice Section. Otago Medical School, P.O. Box 913. Dunedin. New Zealand." Subscription' and advertising information: NZFP. P.O. Box 31-050. Ham. Christchurch. New Zealand. SNZ24.00 for four issues each. year.
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