Who should a male patient with nipple discharge and infection be referred to?

From the Guidelines

A male patient with nipple discharge and infection should be referred to a breast specialist or surgeon for evaluation, as this symptom is uncommon in men and often indicates an underlying pathology that requires specialized assessment. This referral is crucial because nipple discharge in men can be a sign of various conditions, including infection, medication side effects, hormonal imbalances, or more seriously, breast cancer 1. Although breast cancer is rare in men, accounting for less than 1% of all breast cancers, the presence of nipple discharge significantly increases this risk, making prompt specialist evaluation essential for proper diagnosis and treatment.

The specialist will likely perform a physical examination, order imaging studies such as mammography or ultrasound, and possibly recommend a biopsy to determine the cause of the nipple discharge 1. While waiting for the specialist appointment, the patient may be prescribed antibiotics such as dicloxacillin 500mg four times daily for 7-10 days or cephalexin 500mg four times daily for 7-10 days if there are signs of infection like redness, warmth, or purulent discharge. However, antibiotics alone are not sufficient treatment as the underlying cause needs to be identified.

Some key points to consider in the evaluation and management of male nipple discharge include:

• The importance of histologic diagnosis of lesions identified by imaging, as mammography, US, and ductography are unreliable in predicting histologic diagnosis in patients with pathologic nipple discharge 1
• The use of image-guided core biopsy (CNB) as a diagnostic tool, which is preferred over fine-needle aspiration (FNA) and can be therapeutic in some cases 1
• The consideration of major duct excision as a gold standard to exclude malignancy in patients with negative standard evaluation, as a negative ductogram or MRI does not reliably exclude an underlying cancer or high-risk lesion 1

Overall, prompt referral to a breast specialist or surgeon is essential for the proper evaluation and management of male nipple discharge, as it can be a sign of an underlying serious condition that requires specialized care.

From the Research

Referral Options for Male Patients with Nipple Discharge and Infection

• A male patient with nipple discharge and infection should be referred to a breast surgeon for definitive treatment and follow-up 2.
• The patient may also benefit from a consultation with a primary care physician to rule out any underlying infections or conditions that may be contributing to the nipple discharge and infection.
• In some cases, a radiologist may be involved to perform imaging studies, such as mammography or sonography, to evaluate the breast tissue and identify any potential abnormalities 3, 4.

Important Considerations

• Nipple discharge can be a symptom of an underlying malignancy, and it is essential to investigate the cause of the discharge thoroughly 5, 6.
• The presence of a breast lump, bloody nipple discharge, or single duct discharge may increase the risk of underlying breast carcinoma 3, 6.
• A complete central duct excision may be recommended for patients with surgically significant types of discharge, except in women less than 30 years of age or those anxious to have children 6.

Diagnostic Evaluation

• A thorough clinical evaluation, including a physical examination and medical history, is essential to determine the cause of the nipple discharge and infection 2.
• Imaging studies, such as mammography or sonography, may be performed to evaluate the breast tissue and identify any potential abnormalities 3, 4.
• Ductography may be used to localize and resect breast lesions associated with nipple discharge, especially in patients with normal findings on physical examination and other imaging studies 4.