Dr. T. T.
Alagaratnam
FRCS (Eng), FRCS (Ed)
Senior Lecturer, Dept, of Surgery
University of Hong Kong
Summary
The common causes of a discharge from
the nipple and a brief outline of their manage-
ment 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 con-
dition 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
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Discharge From The Nipple
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 con-
ditions in which the abnormal discharge may
be due to physiological causes.
(1) Occasionally women who take oral con-
traceptives 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. Reassur-
ance is all that is necessary and in the
majority of cases the condition usually
subsidies after delivery.
(3) Rarely, young women with rapidly grow-
ing breasts may develop a serous dis-
charge 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 investiga-
tion 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
Nipple discharge
Normal nipple
Lump present No lump present
Localised to one duct From several ducts
I (Duct ectasia — Haagenson's operation)
Duct carcinoma Duct papilloma
(Treat as for (Microdochectomy)
breast cancer)
Fig. 1. Management of nipple discharge
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 dis-
tinguish 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
ulcerated nipple
Paget's disease Minor recurrent Eczema of
(Treat as for trauma nipple
breast cancer)
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 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 practi-
tioner'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.

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