Nipple discharge is the most common complaint among women who visit the breast diagnostic clinic. It can result from both a pathological and physiological processes and represent 3% to 9% of the referral to a breast clinic [1]. The physiological nipple discharge is usually bilateral, nonspontaneous and involves multiple ducts with milky-green color. It is the most frequent in women at a reproductive age. In contrast, the pathological nipple discharge is unilateral and spontaneous and frequently occurs from a single duct with a bloody or serous character. Even though the most common cause of pathological discharge of the nipple is intraductal papilloma (a benign intraductal lesion), duct ectasia, fibrocystic changes of the breast and a malignant or premalignant intraductal lesions are responsible for 5-28% of patients with Pathological nipple discharge. Therefore, all patients with pathological nipple discharge need to undergo evaluation to rule out cancer [2]. Evaluating nipple discharge begins with a clinical assessment. The patient’s history and physical examination results can help differentiate normally occurring physiological discharge from benign and malignant pathological discharge. Diagnostic breast imaging evaluation is not necessary for patients with clinical features of physiologic discharge but is required for patients with suspicious discharge [3].

Ultrasonography is an essential complementary diagnostic device in the exploration of the etiology of nipple discharge [4-5]. It detects 15.1%-63% of mammographic occult malignant lesions, definitely plays a useful role in distinguishing between benign and non-mass lesions such as inspissated secretions with a reported sensitivity of 100% and a specificity of 82.4% [6].

Smear cytology has a low false positive rate of 2.7% and a false negative rate of 20-35%. Despite its inherent flaws, the presence of epithelial cells or red blood cells on smear cytology of patients with PND and normal imaging identifies a group of patients with 10% chance of malignancy and is therefore considered an important diagnostic step in our unit [7]. Studies on the nipple discharge are scare among women; therefore, the study was carried. 

A total of 100 women with nipple discharge attending the Elwyiaa Maternity Teaching Hospital in Baghdad during the period from July 2021 to December 2021 were included in the study. Each woman was interviewed and a file was filled. The requested data was age, marital status, duration of nipple discharge, unilateral or bilateral, character of discharge (serous, bloody, milky and purulent). The finding of imaging as well as cytological results. Chi-square test was used to examine the impact of independent variables (colors of discharge and ultrasound) on the dependent variable (diagnosis). A P value of <0.05 was considered statistically significant.

The mean age of patients was 40.8 years, range from 16 -72 years. Table 1 shows the distribution of cytological picture of nipple discharge according to BI-RADS. BI-RADS >2 was noticed among 6(13%) of those with inflammatory lesion, 4(8.7%) of those with benign lesion and 11(23.9%) of those with malignant lesions. BI-RADS >2 was significant prominent in malignancy (p = 0.01). It was no significantly present among inflammation and benign (p = 0.3 and 0.1, respectively).

Table 2 shows the distribution of colors of discharge among breast lesions. Color of discharge was bloody 5(26.3%) and serous 5(26.3%) in malignant lesions, respectively. It was bloody 5(13.9%) and serous 2(5.3%) of the benign lesions. In inflammatory lesion, the discharge was blood 2(10.5%), serous 4(10.5%) and purulent 3(15.8%). Bloody discharge was significantly prominent in benign and malignant lesions (p = 0.02 and 0.03, respectively).

Nipple discharge is a common complaint observed in routine clinical practice and in most of the cases is related to a benign condition [8]. It accounts 6-10% from the total presenting diseases of the breast [9]. Evaluation of nipple discharge begins with clinical assessment. The patient’s history and physical examination findings can help differentiate normally occurring physiologic discharge from benign and malignant pathological discharge. Diagnostic breast imaging evaluation is required for all females with pathological nipple discharge. Mammography and ultrasound are the first–line examinations to do [3]. Nipple discharge cytology is a simple and fast examination, but strongly limited by a low sensitivity for cancer, with a false negative rate over 50%. Smear of nipple discharge is the way to detect the abnormality (papillary, atypical, suspicious or malignant cells) malignant nipple discharge cytology (C4-C5 categories) is correlated with more high specificity values [10]. This study revealed that most cases of nipple discharge were not malignant. This finding might be explained by the fact that women developed panic on noticing nipple discharge. Neglecting of systemic examination and jumping to the investigation might be attributed this finding. Literatures show medical malpractice in Iraq [11]. In the line of that in literature, serous nipple discharge was the commonest one. The finding that serous nipple discharge was noticed in malignant breast is consistent with other studies [12-15]. This study revealed that serous nipple discharge with in malignant was less than bloody colors. Bloody discharge was a prominent significant feature in benign and malignant. Several articles recommended that bloody discharge is an absolute feature of malignancy [16-19]. The common false information of relating bloody discharge to malignancy leads to panic reactions of women and rushing health services. Women with panic reaction due to bloody discharge go the great attention of medical staff. This might explain the rate of those with discharge. Ultrasound is a useful tool for evaluation of pathologic nipple discharge and can identify lesions not visible on mammography in 63% to 69% of cases. To a certain degree, it can further evaluate mammographic findings to differentiate between benign and suspicious lesions. The advantage of ultrasound is its ability to visualize and detect abnormalities in multiple rather than single ducts [20]. The majority of women (n = 100) underwent ultrasound and only 13(28.9%) were diagnosed malignancy and 8(18.7%) of cases presented with a benign this agrees with other study showed ultrasound detected only 26.3% of malignant lesions [21]. Ultrasound is an important tool not only for the initial evaluation of duct discharge but also to guide biopsy for obtaining a diagnosis and, if needed, guide localization for surgical excision.

Table 1: Distribution Cytological Picture of Nipple Discharge According to Ultrasound Finding

p = 0.02, p = 0.1, p = 0.01

Table 2: Distribution of Color of Nipple Discharge Among Breast Lesions

P = 0.9, p = 0.02, p = 0.03

BI-RADS >2 is related to malignancy; serous nipple discharge is the comments one and bloody and serous nipple discharge related to malignancy.

Financial Disclosure

There is no financial disclosure.

Conflict of Interest

The authors declare no conflict of interest.

Competing Interests

The authors declare no competing interests.

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