Diagnostic Approach to Nipple Discharge

Characterization and Initial Imaging

The American College of Radiology recommends that the appropriate workup for nipple discharge should begin with determining if the discharge is physiologic or pathologic, with ultrasound being the first-line imaging for pathologic discharge in women under 30, and mammography/digital breast tomosynthesis (DBT) being first-line for women over 40 and men over 25 1, 2, 3
Pathologic discharge is characterized by spontaneous occurrence, unilateral presentation, single duct involvement, and bloody, serous, or serosanguineous appearance 4
No imaging workup is needed for physiologic discharge if routine screening is up to date 5, 6

For women under 30 years, ultrasound should be the initial examination (rated 9/9 for appropriateness) 1, 3
For women 30-39 years, either mammography/DBT (rated 9/9) or ultrasound (rated 9/9) can be used as initial examination based on institutional preference 2
For women 40 years and older, diagnostic mammography or DBT should be the initial examination (rated 9/9) 2, 6
For men under 25 years, ultrasound should be the initial examination (rated 9/9), with mammography added as indicated 1, 3
For men 25-30 years, mammography or DBT should be performed as the initial study (rated 8/9) given the high incidence of cancer in men with pathologic nipple discharge 1, 3
For men 30 years and older, mammography or DBT should be the initial examination (rated 9/9) 2

MRI breast with contrast may be considered when initial mammography and ultrasound are negative but clinical suspicion remains high 7, 8
Image-guided core biopsy should be performed for suspicious masses detected on imaging 7, 8
Underlying malignancy can be found in 5-21% of patients with pathologic nipple discharge who undergo biopsy 5
Risk for malignancy increases with age: 3% in patients ≤40 years, 10% in patients 40-60 years, and 32% in those >60 years 7
Men with nipple discharge have a higher risk of malignancy (23-57%) compared to women (16%) 5