What are the possible causes and treatments for nipple pain in a male patient?

Male Nipple Pain: Evaluation and Management

For a male patient presenting with nipple pain, the primary concern is excluding underlying malignancy, which requires diagnostic imaging with mammography as the initial study, complemented by ultrasound, regardless of age—even in men under 30 years old.

Critical Context: High Cancer Risk in Males

Male nipple symptoms carry a substantially elevated malignancy risk compared to females:

• Cancer incidence in males with nipple discharge ranges from 23-57%, which is dramatically higher than the 5-21% rate in females with pathologic nipple discharge 1
• In one institutional series, 57% of males presenting with nipple discharge had underlying malignancy, compared to only 16% in their female cohort 1
• This high pretest probability mandates imaging evaluation even in young males 1

Diagnostic Approach by Age

Males ≥25 Years Old

Initial imaging should be diagnostic mammography with complementary ultrasound 1:

• Mammography serves as the primary modality to detect suspicious microcalcifications and masses 1
• Ultrasound assists with characterization and can guide biopsy if abnormalities are identified 1
• If imaging reveals an abnormality, ultrasound-guided core biopsy is appropriate 1

Males <25 Years Old

Ultrasound may be used as the initial examination, with mammography added as indicated 1:

• The extremely low baseline cancer incidence in very young men allows for ultrasound-first approach 1
• However, given the high cancer association with nipple symptoms in males, mammography should be added if ultrasound shows any suspicious findings 1

Common Benign Causes in Males

While malignancy must be excluded first, benign etiologies include 1:

• Gynecomastia: Most common cause of male breast symptoms, typically presenting as soft, rubbery, or firm mobile subareolar mass that may be painful, especially if present <6 months 1
• Pseudogynecomastia: Excess fatty tissue deposition, particularly in patients with elevated BMI 1
• Skin and subcutaneous lesions: lipomas, epidermal cysts, oil cysts 1

Key Clinical Distinctions

Physical examination findings to assess 1:

• Location: Gynecomastia typically presents directly under the nipple
• Consistency: Soft, rubbery, or firm mobile mass suggests gynecomastia
• Bilaterality: Gynecomastia is bilateral in approximately 50% of cases
• Pain: More common with gynecomastia than cancer, especially recent-onset gynecomastia

Critical Pitfall to Avoid

Do not assume benign etiology based on clinical examination alone in males with nipple symptoms. Approximately 50% of men with breast cancer have coexisting gynecomastia, though gynecomastia itself is not a risk factor for cancer 1. The high malignancy rate (23-57%) associated with male nipple discharge mandates imaging evaluation regardless of physical examination findings 1.

Advanced Imaging Considerations

If initial mammography and ultrasound are negative but symptoms persist 1:

• MRI or ductography may be considered, though there is limited literature supporting their use specifically in males with nipple discharge 1
• MRI has demonstrated higher positive and negative predictive values than ductography for detecting high-risk lesions in patients with pathologic nipple discharge 1

Treatment Approach

Management depends entirely on imaging findings 1:

• If imaging identifies a suspicious abnormality: proceed to image-guided core biopsy 1
• If imaging confirms isolated gynecomastia with typical features: clinical observation is appropriate, though imaging does not routinely need to be performed if clinical findings are clearly consistent with gynecomastia 1
• If malignancy is confirmed: urgent surgical referral