Nipple Discharge

1
Nipple Discharge

• Dale Reynolds, M.D
• UT Houston HSC
• Division of Plastic Surgery

2
Nipple DischargeDefinition

• Fluid that escapes spontaneously from the nipple

3
Nipple Discharge

• 5 of the referrals to breast clinics
• 10 - 15 of patients with benign breast disease
• 3 of patients with carcinoma

4
Assessment

• Complete history
• Complete physical examination
• Mammogram
• Cytology
• Record site and character of discharge
• Test for hemoglobin
• Ductography

5
Evaluation of Discharge

• Spontaneous or elicited
• Seek duct or ducts producing the discharge
• Number of ducts involved
• Color and consistency of discharge
• Trigger point on breast
• Any associated mass
• Presence or absence of heme

6
Types of Discharge

• Milky
• Multicolored and sticky
• Purulent
• Clear and watery
• Yellow or serous
• Pink or serosanguineous
• Bloody or Sanguineous

7
Physiologic/Non surgically Significant Discharge

• Not spontaneous
• Arise from multiple ducts
• Usually bilateral
• 2/3 of non lactating women can express fluid

8
Physiologic/Non surgically Significant Discharges

• Purulent
• Multicolored and Sticky
• Milky/Galactorrhea

9
Purulent Discharge

• Produced by an infection
• Mostly child bearing age women
• Unilateral spontaneous discharge from multiple
  ducts
• Pain, tenderness
• Inflammation

10
Treatment of Purulent Discharge

• Antibiotics
• Incision and Drainage
• Biopsy of wall to r/o cancer

11
Multicolored Discharge

• Mostly green, yellow, white, brown, gray
• Ages 30-60
• Association with mammary duct ectasia
• Mammary duct - associated inflammatory disease
  sequence

12
Milky Discharge/Galactorrhea

• Bilateral
• Spontaneous
• Multiple ducts
• Child bearing years
• Non pregnant
• Not breast feeding

13
Galactorrhea Cont..

• Most common 1-2 years after pregnancy
• Increased production of prolactin
• Endocrine anovulatory syndrome
• Phenothiazines, tricyclics, rauwolfa alkaloids,
  methyldopa, oral contraceptives
• Hypothyroidism
• Pituitary adenoma

14
Galactorrhea Diagnosis

• Thin layer chromatography
• Radioimmunoassay for prolactin levels
• CT of Sella Turcica

15
Galactorrhea Therapy

• Large doses of estrogen and progesterone
• Bromocriptine mesylate
• Cabergoline
• Clomiphene
• Removal of adenoma
• Bilateral total duct ligation

16
Pregnancy

• Bloody Discharge is common
• 20 of discharges during pregnancy
• Hypervascularity of the breast
• Benign
• No treatment required

17
Other Nipple Discharges

• Inverted Nipples
• Eczematoid lesions
• Traumatic erosions
• Herpes Simplex
• Infections
• Montgomery gland abscesses
• Mammary duct fistulas

18
Pathologic/Surgically Significant Discharges

• Spontaneous
• Unilateral
• Localized to a single duct
• Persistent
• Intermittent
• Non lactation

19
Pathological/Surgically Significant continued

• Clear or watery
• Yellow or Serous
• Pink or serosanguineous
• Bloody or sanguineous

20
Cancer Association

• Water 35
• Sanguineous 28
• Serosanguineous 13
• Serous 6
• Accompanied by a mass
• Age over 40
• Cytological and mammography findings

21
Etiology of Pathological Discharge

• Intraductal Papilloma
• Multiple intraductal papillomas
• Juvenile Papillomatosis
• Carcinoma

22
Intraductal Papilloma

• Develop in major subareolar duct
• Most common cause of serous and serosanguineous
  discharge
• 50 have bloody discharge
• 1/3 have palpable mass
• Treated by microdochectomy

23
Multiple Intraductal Papilloma

• 10 of intraductal papillomas
• Discharge is less common
• Increased association of breast carcinoma

24
Juvenile Papillomatosis

• Rare condition
• Ages 10-44
• Discrete mass lesion
• Treated by complete excision

25
Carcinoma

• 14-34 of DCIS present with unilateral discharge
• 25 of ductal carcinomas present with discharge
• Palpable mass
• Pagets changes
• Microdochectomy for diagnosis

26
Operative Therapy

• Microdochectomy
• Total duct excision

27
The End