Practice 10 Minute Consultation

Nipple discharge

BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h3123 (Published 21 July 2015) Cite this as: BMJ 2015;351:h3123
  1. Peter Lawrence Zaki Labib, specialist trainee year 3, general surgery1,
  2. Nick Gallegos, consultant breast surgeon2,
  3. David Hegarty, general practitioner3
  1. 1Torbay Hospital, Torquay TQ2 7AA, UK
  2. 2Weston General Hospital, Uphill, Weston-super-Mare BS23 4TQ, UK
  3. 3Wychbury Medical Group, Stourbridge DY9 9DS, UK
  1. Correspondence to: P L Z Labib peter.labib{at}nhs.net
  • Accepted 20 February 2015

The bottom line

  • If a patient is over 50 years old with discharge, retraction, or other changes of concern affecting one nipple only, refer urgently to a breast clinic for review within two weeks

  • Beware of inflammatory breast cancer or Paget’s disease of the breast, which may be confused with mastitis, breast abscess, or unilateral eczema

A 45 year old woman presents with unilateral bloodstained nipple discharge. On examination, there is no palpable breast lump and no axillary or supraclavicular lymphadenopathy.

What you should cover

History

Discharge colour—Although discharge colour is a not an accurate diagnostic tool, bloodstained discharge is always abnormal and one should have a high index of suspicion for a serious underlying pathology.1 Galactorrhoea, the inappropriate secretion of breast milk in men or women who aren’t breast feeding, is likely to be endocrine in origin.

Unilateral or bilateral—Discharge from both breasts usually indicates a systemic cause; either physiological (such as lactational), endocrine (such as prolactinoma, hypothyroidism) or iatrogenic (such as medications). Unilateral discharge indicates a local cause, such as a ductal papilloma, breast cyst, or ductal carcinoma.

Associated symptoms—Nipple discharge can occur as an isolated complaint or as part of a constellation of local …

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