Red Flags:

· Milky discharge which is bilateral and profuse and spontaneous in a non-pregnant woman – PROLACTIN if the woman is amenstrual

· Blood / Clear / Serous – EVALUATE – most likely diagnosis is Intraduct Papilloma

· Nipple retraction – not significant if P1 M1 especially if correctable

Mg if >40 unless multiduct bilateral discharge, which is physiological.

US if palpable abnormality only

NO NIPPLE CYTOLOGY – this is unhelpful therefore not recommended

Punch Biopsy for nipple ulceration or eczema (Refer back to GP for treatment, we are not dermatologists)

Uniduct bloody or clear discharge needs surgical diagnostic treatment

<35 microductectomy

>35 or those not wishing to breast feed in future: Hadfields total duct excision

Profuse milky discharge – if prolactinoma excluded, consider short course of cabergoline, as for cessation of breast feeding.

Purulent Discharge with Peri-areolar pain and swelling

Most likely diagnosis is peri-ductal mastitis. This is more common in smokers and often has an anaerobic component. Co-amoxiclav is the antibiotic of choice, or erythromycin and metronidazole in penicillin allergic individuals. Encourage the patient to stop smoking.

If it fails to settle, aspiration or even I&D under LA in the clinic may be required.

Elective Hadfields should be done only when the infection has settled and should be covered by antibiotics, started 2 days prior to the procedure and given for 5 days in total.

Mammary duct Fistula

Treat as for Peri-ductal mastits.