Nipple Discharge Evaluation and Management

Introduction to Nipple Discharge

The American College of Radiology states that nipple discharge has well-established causes that fall into distinct categories, including physiologic and pathologic causes 1, 4
Physiologic nipple discharge is characterized by bilateral, multiple duct orifices, provoked (not spontaneous), and white/green/yellow color, with a prevalence of 50-80% in reproductive-age women 1, 2, 4, 5
The American College of Radiology recommends that patients with physiologic discharge do not require further radiologic investigation if they have up-to-date screening 2, 5

Pathologic nipple discharge is characterized by at least one of the following: spontaneous, unilateral, single-duct orifice, serous or bloodstained, with benign etiologies being the most common, including intraductal papilloma/papillomatosis (35-48% of cases) and duct ectasia (17-36% of cases) 1, 3, 4
The National Comprehensive Cancer Network states that pathologic nipple discharge has a malignancy risk of 11-16% in larger studies, though ranges from 3-29% depending on population and discharge characteristics 1, 4, 5
The American College of Radiology recommends diagnostic mammography as the first-line imaging for pathologic nipple discharge, regardless of port presence, with ultrasound of the retroareolar region being complementary to mammography 1, 2, 9

The American College of Radiology recommends evaluating the discharge itself rather than attributing it to the port, and characterizing the discharge based on laterality, number of ducts, spontaneity, and color 1, 2, 4
The National Comprehensive Cancer Network states that medication effects, such as chemotherapy or other medications administered through the port, may cause hyperprolactinemia and galactorrhea 6, 7
The American College of Radiology recommends surgical duct excision for pathologic discharge, even with negative imaging, as this provides both diagnosis and treatment 6, 7