Nipple Discharge
This is a common problem. It is embarrassing for the patient, as discharge may leak through and stain clothing. Bloodstained nipple discharge may be due to an underlying carcinoma.
History
Pregnancy or lactation will be apparent. Discharge may occur from the nipples of newborn babies of either sex (witch’s milk). It is due to the passage of female hormones across the placenta. Discharge, either serous or milky, may occur at puberty. Cyclical mastalgia with a coloured discharge, especially greenish, suggests fibroadenosis. A patient in the fifth decade with a history of retroareolar pain and a thick creamy discharge may have duct ectasia. A bloodstained discharge must be taken seriously and fully investigated. The patient may describe this as frank, red blood or altered blood, which may be darkish brown. It is important to know whether it has come from one duct or several. Does the patient have an underlying lump? Profuse milky discharge associated with amenorrhoea will suggest the possibility of prolactinoma of the anterior pituitary gland. Jogger’s nipple is fairly common in male athletes. It is more common in male athletes than females, since most women wear a bra when working out and that protects the nipple. Jogger’s nipple occurs when the nipple and the areola become irritated as the nipple rubs up against damp, rough fabric. Crusting, soreness and even bleeding of the nipple tissue occur.
Examination
Is the discharge obvious? It may have stained the clothes and the colour of it may be apparent. Is it associated with a painful and lumpy breast to suggest fibroadenosis? Is it possible to express the discharge by manual pressure? Occasionally it is possible, by manual pressure on specific areas of the breast, to express blood from one particular duct. Is there an underlying discrete lump suggestive of a carcinoma? Is there retroareolar tenderness, lumpiness and nipple retraction, suggestive of duct ectasia? Are there any signs of infection or abscess? Has the nipple been destroyed, as in Paget’s disease? If prolactinoma is suspected (galactorrhoea, amenorrhoea, infertility), the visual fields should be checked, as a macroadenoma of the anterior pituitary gland may impinge on the optic chiasma. In jogger’s nipple, there will be crusting, fissuring and bleeding from nipple tissue.
