Nipple symptoms

Breast Cancer accounts for 30% of cancers in woman and around 4,500 people are diagnosed with Breast Cancer in Scotland each year; approximately 25 of these are men.

USOC Referral should be made for:

Visibly bloodstained discharge
New unilateral nipple retraction (which is not reversible on examination)
Nipple eczema if unresponsive to topical steroids after a maximum of 2 weeks

(Details of other indications for Breast USOC referral can be found under pages for Skin Changes, Breast Lumps and Breast Abscess).

Details of all referral categories can be found below under Referral Guidelines.

Please also see Nipple Problems, CsfD national pathway for further information.

Who to refer, who not to refer, how to refer

Who to refer:

Urgent Suspicion of Cancer Referral:

Visibly bloodstained discharge
New Unilateral fixed nipple retraction (which is not reversible or intermittent)
Nipple eczema if unresponsive to topical steroids after a minimum of 2 weeks

Routine Referral

Persistent unilateral spontaneous discharge sufficient to stain outer clothes
Nipple Discharge (only, no lump or other abnormality suggestive of cancer present):
- If 50 years or older then REFER
- If less than 50 years of age and a single duct, large volume, persistent or occult blood staining (discharge can be checked for blood using urinalysis dipstick) then REFER
- If less than 50 years of age, and multiple ducts, then watchful waiting unless any of the above factors are present. If persistent then can REFER.
- If the discharge is profuse and milky then check prolactin level before referring. A prolactin level of > 1000mU/L is significant.

Who not to refer:

Transient nipple discharge which is not bloodstained (check Prolactin levels when bilateral discharge present)
Check prolactin levels when discharge present
Longstanding nipple retraction
Reversible/intermittent nipple retraction
Nipple eczema if eczema present elsewhere

How to refer:

Please refer via SCI Gateway to BGH

Borders General Hospital >> General Surgery – Breast >> LI Breast – Urgent

Borders General Hospital >> General Surgery – Breast >> LI Breast – Non Urgent

Primary care management

Women who can be managed, at least initially, by their GP include:

Women under 50 who have nipple discharge that is from more than one duct, or where the discharge is intermittent and is neither bloodstained or troublesome. The number of ducts involved can usually be established by asking women to demonstrate discharge.
To check for occult blood staining discharge can be checked using urinalysis dipstick.
If the discharge is profuse and milky then check prolactin level before referring. A prolactin level of > 1000mU/L is significant.