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658 SECTION 11: Obstetrics and Gynecology DISPOSITION AND FOLLOW-UP Guidelines for admission ( Table 103-6) and inpatient treatment (Table 103-4) have evolved over the past decade. Among the problems encountered with outpatient care are the provision of adequate guidelinedriven treatment, patient adherence to the prescribed therapeutic regimen, difficulty in arranging outpatient administration of parenteral medications, coordination of 72-hour follow-up evaluation, and partner treatment, all of which have been implicated as causes of treatment failure. Consider these and other constraints when determining the patient’s ability to follow or tolerate an outpatient regimen. Institutions should consider adoption of protocolized treatment guidelines to help to ensure fidelity to standards of care. Admission decisions in the ED are based on severity of illness, likelihood of adherence to outpatient medication regimen, likelihood of major anaerobic infection (IUD, suspected pelvic or tubo-ovarian abscess, or history of recent uterine instrumentation), certainty of diagnosis, coexisting illness and immunosuppression, pregnancy, patient age, and other major fertility issues. If the patient is discharged, arrange reevaluation within 72 hours for clinical improvement and adherence to the prescribed regimen. Encourage partner evaluation and treatment. Test and treat for other sexually transmitted infections if not already done. Educate patients about the use of barrier contraceptives and other “safe sex” techniques to lessen the risk of reinfection. Counsel the patient to remain abstinent from sexual activity until 1 week after treatment is finished for both the patient and partner and symptoms have abated. Partner treatment is crucial to preventing repeated episodes of PID. This can be difficult to ensure. If the current partner has accompanied the patient to the ED, and the patient is willing to tell this partner about FIGURE 103-1. Tubo-ovarian complex. Endovaginal image of left adnexa shows a distorted ovary (OV) partially encircled by a fluid-filled hydrosalpinx (TUBE). [Reproduced with permission from Ma OJ, Mateer JR, Reardon RF, Joing SA (eds): Ma & Mateer’s Emergency Ultrasound, 3rd ed. New York, NY: McGraw-Hill Education, Inc.; 2014. Fig. 16-17 Part A, p. 469.] TABLE 103-6 Admission Considerations •  Inability  to exclude surgical emergency from the differential diagnosis •  Pregnancy •  Failure  to respond to outpatient treatment •  Inability  to tolerate or comply with outpatient treatment •  Severe  toxicity, high fever, nausea, vomiting •  Tubo-ovarian  abscess Source: Reproduced with permission from Centers for Disease Control and Prevention, Workowski KA, Berman SM: Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 59(RR-12): 12, 2010. her infection, she can be asked to suggest immediate ED evaluation to her partner. If not, the patient should be instructed to notify partners with whom she has had sexual contact in the 60 days preceding the onset of her symptoms to go to the local public health department or sexually transmitted infection clinic for empiric treatment of N. gonorrhoeae and C. trachomatis. A 6-minute PID outreach video has been developed and was found in one randomized controlled trial to improve partner treatment. Recent European guidelines suggest the use of doxycycline as empirical treatment of partners to reduce exposure to macrolide to avoid increasing resistance in M. genitalium.

nd C. trachomatis. A 6-minute PID outreach video has been developed and was found in one randomized controlled trial to improve partner treatment. Recent European guidelines suggest the use of doxycycline as empirical treatment of partners to reduce exposure to macrolide to avoid increasing resistance in M. genitalium. Acknowledgment: The authors gratefully acknowledge the contribu tions of Amy Behrman and William Shoff, coauthors of this chapter in previous editions. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Breast Disorders Bophal Sarha Hang INTRODUCTION The most common breast complaints in the ED involve breast pain, breast mass, nipple discharge, infection, or postoperative complications. Approximately 30% of women will present to a physician with a chief complaint related to the breasts. 1 Although the problems are rarely emergent except when systemic symptoms such as fever are present, concerns about the potential for breast cancer contribute to patient anxiety. PATHOPHYSIOLOGY Adult breast is composed of approximately 20% glandular tissue, and the remaining breast volume consists of fat and connective tissue that give the breast its characteristic texture and shape. Glandular lobules drain into lactiferous ducts, which converge and open at the nipple. The nipple is an important landmark located over the fourth intercostal space. Normal breast tissue extends from the sternocostal junction medially to the midaxillary line laterally and from the second to the sixth ribs in the midclavicular line. An axillary tail of breast tissue often extends into the axilla. Blood supply arises from the internal mammary, lateral tho racic, thoracodorsal, and subscapular arteries, whereas venous drainage starts in the subareolar plexus and empties into the intercostals, internal mammary, and axillary veins. Lymphatic drainage of the breast is pri marily to the axilla, with a small portion going to internal mammary lymph nodes. Cyclic variances in estrogens, progesterone, follicle-stimulating hor mone, and luteinizing hormone signal stromal and glandular changes in breast physiology. CLINICAL FEATURES  HISTORY Ask the patient about onset of any mass or pain, location of the affected area, and duration of the symptoms. Complaints that vary with menses suggest a benign cause, whereas cancers are often asymptomatic. Radiation of the pain to any other body site is particularly important when a CHAPTER Tintinalli_Sec11_p0607-0668.indd 658 8/2/19 4:21 PM

set of any mass or pain, location of the affected area, and duration of the symptoms. Complaints that vary with menses suggest a benign cause, whereas cancers are often asymptomatic. Radiation of the pain to any other body site is particularly important when a CHAPTER Tintinalli_Sec11_p0607-0668.indd 658 8/2/19 4:21 PM CHAPTER 104: Breast Disorders 659 increased pituitary secretion of prolactin. Hypercortisolism (Cushing’s disease) and acromegaly due to elevated growth hormone levels are both associated with galactorrhea. Evaluation of the patient with galactorrhea focuses on any history of associated menstrual abnormalities and the presence of acne, hirsutism, infertility, or libido changes. Symptoms of increased intracranial pres sure and hypothyroidism should be investigated. All medications and dietary supplements should be reviewed. The physical examination includes evaluations of the visual fields, breasts, skin, and thyroid gland. ED studies include a urine or serum pregnancy test and may include neuroimaging (CT or MRI) and neurosurgical consultation if there is concern for an intracranial mass. Treat ment for galactorrhea, other than the discontinuation of a medication suspected to be causative, is deferred to the primary care physician or the follow-up specialist.  COMPLICATIONS OF LACTATION Breast engorgement usually presents on the third to fifth postpartum day, with symptoms of painful, hard, and enlarged breasts. The pain may be accompanied by nausea and low-grade fever. Engorgement results from inadequate removal of milk from the breast. This may be due to infant separation, sore nipples, or improper breastfeeding techniques. Ensuring proper latch-on while breastfeeding or pumping usually alleviates the pain and allows for decompression of the nipple-areola complex. Warm showers or manual massage may also help facilitate milk letdown and relieve pain due to engorgement. Nipple irritation or soreness is common and usually caused by poor positioning or latch-on techniques. Other causes include trauma, plugged ducts, candidiasis, and inflammatory skin disorders. Purified lanolin cream, analgesics, and breast shields may help facilitate healing. There may be some benefit to applying expressed breast milk to nipples. 4,5 Reynaud’s phenomenon can cause nipple pain in some women and may respond to topical nefedipine.6 Puerperal mastitis presents with severe pain, tenderness, swelling, and redness. Patients may also develop fever, chills, and myalgias. Mas titis most commonly presents in the second postpartum week due to milk stasis and retrograde infection. Differentials include marked breast engorgement, clogged milk duct, and inflammatory carcinoma, a rare condition. Mastitis, like other inflammatory processes, has the US appear ance of hypoechoic fluid surrounding subcutaneous fat lobules with out a discrete fluid collection ( Figure 104-1), in contrast to abscess (Figure 104-2), which presents as a hypoechoic (dark) fluid collection in the tissue with the absence of vascular signals.

itis, like other inflammatory processes, has the US appear ance of hypoechoic fluid surrounding subcutaneous fat lobules with out a discrete fluid collection ( Figure 104-1), in contrast to abscess (Figure 104-2), which presents as a hypoechoic (dark) fluid collection in the tissue with the absence of vascular signals. TABLE 104-1 Causes of Elevated Prolactin Levels Physiologic causes Sleep, stress, exercise, volume depletion, intercourse or orgasm, pregnancy, breast stimulation, seizures Abnormal stimulation of the chest wall Surgery, trauma, herpetic infection Damage to or disruption of the pituitary stalk — Endogenous hypothalamicpituitary signaling — Neoplasms Prolactinomas, renal cell carcinoma, lymphoma, craniopharyngioma, bronchogenic carcinoma, hydatidiform mole Medications Antidepressants (monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, tricyclic antidepressants), antihypertensives (atenolol, methyldopa, reserpine, verapamil), antipsychotic phenothiazines, antihistamines, herbs and vitamin supplements (anise, fennel, nettle, clover, thistle, fenugreek seed), amphetamines, cocaine, opioids, marijuana Systemic disease Chronic renal failure, hypothyroidism, hypercortisolism (Cushing’s disease), acromegaly malignancy is suspected. The presence of symptoms in the contralat eral breast parenchyma is also more reassuring for a benign diagnosis. Assess the color and consistency of any nipple discharge. Changes that the patient notes on breast self-examination may be significant and should be correlated with the menstrual cycle. Ask about family history, specifically about first-degree relatives with breast cancer and other risk factors (delay of childbearing to after age 30 years, biopsy confirmation of atypical hyperplasia, or history of chest irradiation). However, most women who develop breast cancer have no obvious risk factors beyond the two strongest factors, namely, female gender and age. More than 50% of breast cancers are diagnosed in women ≥65 years of age, and women <30 years of age are diagnosed with <1% of all breast cancers.  PHYSICAL EXAMINATION The breast examination includes both inspection and palpation. Compare the breasts with the patient sitting upright, and note any breast asymmetry or skin dimpling. Also examine the axillae, including the mammary tail and lymph nodes, in the sitting position. Perform the rest of the examination with the patient supine and the ipsilateral hand behind the head. Examine the upper outer quadrant of each breast with extra care, because about half of breast carcinomas originate in that area, with a higher propensity for left-sided involvement. 2,3 Examine the nipple-areola complex with gentle manipulation to detect subareolar masses and latent nipple discharge. Women with breast augmentation may be challenging to examine, but give attention to tissue changes or deviation of the implant. DISORDERS OF THE LACTATING BREAST  ABNORMAL LACTATION Any inappropriate secretion of milky discharge from the breast is called galactorrhea. Galactorrhea often results from abnormally elevated levels of prolactin, although some women have normal prolactin levels on testing. Hyperprolactinemia may be caused by inadequate inhibition of secretion or increased production of prolactin. Causes of elevated pro lactin levels are listed in Table 104-1. Prolactinomas, benign anterior pituitary neoplasms, are distinguished by symptoms of galactorrhea, amenorrhea, hirsutism, facial acne, visual field deficits, and headaches. Chronic renal failure results in a dimin ished capacity to clear circulating prolactin. Hypothyroidism causes increased levels of thyrotropin-releasing hormone, which results in FIGURE 104-1.

plasms, are distinguished by symptoms of galactorrhea, amenorrhea, hirsutism, facial acne, visual field deficits, and headaches. Chronic renal failure results in a dimin ished capacity to clear circulating prolactin. Hypothyroidism causes increased levels of thyrotropin-releasing hormone, which results in FIGURE 104-1. Mastitis, like other inflammatory processes, has the US appearance of hypoechoic fluid surrounding subcutaneous fat lobules without a discrete fluid collection (arrows). Tintinalli_Sec11_p0607-0668.indd 659 8/2/19 4:21 PM

plasms, are distinguished by symptoms of galactorrhea, amenorrhea, hirsutism, facial acne, visual field deficits, and headaches. Chronic renal failure results in a dimin ished capacity to clear circulating prolactin. Hypothyroidism causes increased levels of thyrotropin-releasing hormone, which results in FIGURE 104-1. Mastitis, like other inflammatory processes, has the US appearance of hypoechoic fluid surrounding subcutaneous fat lobules without a discrete fluid collection (arrows). Tintinalli_Sec11_p0607-0668.indd 659 8/2/19 4:21 PM 660 SECTION 11: Obstetrics and Gynecology Puerperal mastitis is caused by Staphylococcus aureus in 40% of cases, although Escherichia coli and Streptococcus species are also known pathogens. Consider community-acquired methicillin-resistant S. aureus infections associated with puerperal mastitis and abscess. 5 There is no need to interrupt breastfeeding. Treatment requires frequent analgesia, breast emptying, and antibiotics with antistaphylococcal penicillins or cephalosporins (Table 104-2). Sulfamethoxazole-trimethoprim cannot be given to lactating mothers with infants <2 months old. If the infection fails to respond rapidly to antibiotics, evaluate for abscess and broaden antibiotic coverage. Breast abscess is uncommon and complicates mastitis in approxi mately 3% of cases. If US examination identifies a subcutaneous fluid collection, US-guided drainage is an initial first-line treatment (Figures 104-1 and 104-2). Breastfeeding should be continued throughout the course of treatment unless the antibiotic regimen is contraindicated with newborns. 4,7 Surgical drainage is reserved as a last resort in lactating patients to avoid the potential for milk fistulas. 8 Management also includes antibiotic coverage for possible drug-resistant Staphylococcus such as oral cephalosporins or clindamycin. Intravenous vancomycin is a good choice for septic patients requiring inpatient hospitalization. In a subset of patients with recurrent infections, the surgeon may need to perform an excisional biopsy of tissue to rule out an associated inflammatory carcinoma. INFLAMMATORY BREAST CONDITIONS The differential diagnosis of an inflamed breast includes infectious mastitis, breast abscess, periductal mastitis, ruptured breast cyst, inflammatory neoplasm, metastatic cancer from a primary lesion, tuberculosis, and Paget’s disease. Each entity can mimic the other, more benign conditions. A failure of the condition to improve with antibiotic therapy indicates the need for urgent surgical consultation and possible biopsy to exclude the presence of an inflammatory cancer.  CELLULITIS, ACUTE MASTITIS, AND BREAST ABSCESS IN NONLACTATING WOMEN Cellulitis, mastitis, and breast abscesses exist along a continuum, with similar clinical presentation of pain, redness, swelling, fever, and malaise. Cellulitis can be identified on US as diffuse thickened and hyperechoic skin and increased echogenicity of subcutaneous tissue. However, breast cellulitis is uncommon and requires referral to a breast surgeon for imaging and possibly biopsies. Initial treatment includes dicloxacillin, amoxicillin–clavulanic acid, or a first-generation cephalosporin. How ever, the increasing incidence of infection with methicillin-resistant S. aureus may necessitate the use of trimethoprim-sulfamethoxazole, clindamycin, or tetracycline depending on the patient’s history of infections and the local prevalence of methicillin-resistant S. aureus. Cellulitis requires follow-up with a breast surgeon. Acute mastitis and abscesses in nonlactating women (Figures 104-1 and 104-2) are often seen in women with diabetes, obesity, or a history of smoking. Common organisms are Staphylococcus and Streptococcus. Follow-up mammography is recommended for patients older than 30 years and should be done after the acute phase has resolved.

titis and abscesses in nonlactating women (Figures 104-1 and 104-2) are often seen in women with diabetes, obesity, or a history of smoking. Common organisms are Staphylococcus and Streptococcus. Follow-up mammography is recommended for patients older than 30 years and should be done after the acute phase has resolved. 11 Initial recommended empiric parenteral antibiotics are third-generation cephalosporins (e.g., ceftazidime), clindamycin, van comycin, fluoroquinolones, or linezolid with consideration of the addition of metronidazole for deeper abscesses. The prevalence of methicillin-resistant S. aureus infections continues to increase and has been reported in up to 20% of cases of breast abscess. Patients without systemic toxicity can be treated as outpatients. Antibiotics should provide anaerobic coverage. Infections should respond to antibiotics within 48 hours. Refer patients to a breast surgeon for USguided needle aspiration and therapy. 12-15  HIDRADENITIS SUPPURATIVA Hidradenitis suppurativa frequently presents with recurrent multiple cutaneous abscesses, sinus tracts, and scarring of the breast folds, axillae, and groin and perineum. It is a chronic inflammatory disease involving the obstruction of sweat glands and polymicrobial colonization, usually with Staphylococcus and Streptococcus species. Frequently, patients present with painful superficial cutaneous abscesses along the inferior, pendulous surface of the breast and require surgical drainage for pain relief. Incision and drainage usually are adequate therapy for a limited area of abscess formation. Antibiotics are rarely used for outpatient management of hidradenitis abscesses in immunocompetent patients, although clindamycin or rifampin may be used by dermatologists or surgeons to decrease the frequency and severity of the disease. There is no cure, and the disease often requires extensive surgical excision of the apocrine tissue.  INFLAMMATORY BREAST CANCER Of all the potential presentations of a breast malignancy, inflammatory breast cancer is the entity associated with the highest mortality and longest delay from initial presentation to definitive diagnosis. The clinical presentation is characterized by symptoms of mastalgia and breast inflammation due to tumor infiltration of dermal lymphatics and inflammation of the breast stroma. The combination of erythema and edema results in the classic peau d’orange appearance of the overlying skin and ultimately nipple retraction as the edema progresses. Initially, the patient presents with a clinical syndrome of breast enlargement, breast warmth, tenderness, edema, erythema, and sometimes discolor ation of the overlying skin. The absence of a palpable underlying mass or axillary lymphadenopathy does not rule out the diagnosis. The signs of inflammatory breast cancer are often indistinguishable clinically from infection. Prompt mammography and biopsy of the skin and any palpable or radiographic breast lesions will be required by the follow-up physician. Similarly, the diagnosis of inflammatory breast cancer must be considered promptly if there is not an initial good response to antibiotics or if breast cellulitis or abscess fails to completely resolve. NONINFLAMMATORY PAINFUL BREAST DISORDERS  MASTODYNIA Breast pain is also termed mastodynia or mastalgia. Irritation to the intercostal nerves at T3-T5 can cause pain in the breast or nipple. The pain is bilateral and usually most severe in the upper outer quadrants of the breast. Pain may be referred to the axilla or scapula. Diagnosis relies on findings of the history and physical examination to confirm that the pain actually originates from the breast. Breast pain is an uncommon symptom of breast cancer.

The pain is bilateral and usually most severe in the upper outer quadrants of the breast. Pain may be referred to the axilla or scapula. Diagnosis relies on findings of the history and physical examination to confirm that the pain actually originates from the breast. Breast pain is an uncommon symptom of breast cancer. 16 Cyclic mastodynia is usually most severe in the immediate premenstrual phase and decreases or resolves completely following menstruation. At times, the examination reveals tender, nodular breasts, which suggests a diagnosis of fibrocystic changes, although breast cancer must remain in the differential diagnosis. For most patients, reassurance and use of a supportive bra provide adequate initial FIGURE 104-2. Breast abscess presents as a hypoechoic (dark) fluid collection in the tissue (arrows) with the absence of vascular signals. Tintinalli_Sec11_p0607-0668.indd 660 8/2/19 4:21 PM

er must remain in the differential diagnosis. For most patients, reassurance and use of a supportive bra provide adequate initial FIGURE 104-2. Breast abscess presents as a hypoechoic (dark) fluid collection in the tissue (arrows) with the absence of vascular signals. Tintinalli_Sec11_p0607-0668.indd 660 8/2/19 4:21 PM CHAPTER 104: Breast Disorders 661 treatment. Refer to a primary care physician for follow-up treatment and consideration of imaging.17,18 SKIN AND NIPPLE ABNORMALITIES  NIPPLE DISCHARGE Table 104-3 lists some common causes of nipple discharge. In general, nipple discharge that is bilateral, occurs with nipple manipulation, and can be expressed from several ducts is not suggestive of cancer. Nipple discharge that originates in a single breast, emanates from a single duct, and is clear, pink, bloody, or serosanguineous is associated with an increased risk of carcinoma. 19 Follow-up with the patient’s primary care physician for mammography and possible fluid analysis of the discharge is always needed. Intraductal papillomas usually present with a unilateral bloody nipple discharge in women from 20 to 40 years of age. Bleeding is secondary to increased tissue vascularity. A mass may not be palpable on examination. Other causes of bloody nipple discharge include mammary duct ectasia and breast cancer. Ductal ectasia involves the stasis or plugging of lactiferous ducts, which then progresses to an infiltrative inflammatory process. The cause of mammary duct ectasia is unknown. Bilateral spontaneous milky nipple discharge can indicate an elevated serum prolactin level (see earlier discussion under “ Abnormal Lactation”). Any postmenopausal nipple discharges are significant, so refer to a breast specialist.  MONDOR’S DISEASE Mondor’s disease is a benign, self-limited superficial thrombophlebitis, usually seen in young women of childbearing age. Patients present with TABLE 104-2 Mastitis, Abscess, and Hidradenitis Signs and Symptoms Treatment Comments Puerperal mastitis Erythematous area on breast with area of well-localized pain Fever, chills, myalgias, flulike symptoms Frequent breast emptying Routine hand washing prior to breast manipulation Analgesia Antibiotics: Dicloxacillin, 500 milligrams four times a day for 10–14 d Cephalexin, 500 milligrams four times a day for 10–14 d Clindamycin, 300 milligrams four times a day for 10–14 d Occurs during first few month or weeks postpartum. Breastfeeding may continue. Early antibiotics and milk drainage are cornerstone of treatment. Must rule out abscess if rapid response to antibiotics does not occur. Cover for MRSA. US to differentiate mastitis from abscess. Follow up with obstetrician. Nonpuerperal mastitis Erythematous area on breast with area of well-localized pain Fever, chills, myalgias, flulike symptoms Analgesia Antibiotics: Dicloxacillin, 500 milligrams four times a day for 10–14 d Cephalexin, 500 milligrams four times a day for 10–14 d Clindamycin, 300 milligrams four times a day for 10–14 d TMP-SMX, 160/800 milligrams twice a day Must rule out abscess if rapid response to antibiotics does not occur. US helps differentiate between mastitis and abscess. Follow up with surgeon. Breast abscess Erythematous area on breast with area of well-localized pain Fever, chills, myalgias, flulike symptoms US-guided needle aspiration for abscess Analgesia Antibiotics: Dicloxacillin, 500 milligrams four times a day for 10–14 d Cephalexin, 500 milligrams four times a day for 10–14 d Clindamycin, 300 milligrams four times a day for 10–14 d TMP-SMX, 160/800 milligrams twice a day Needle aspiration is first-line treatment. Obtain surgical consultation for treatment failure and multiloculated abscesses.

500 milligrams four times a day for 10–14 d Cephalexin, 500 milligrams four times a day for 10–14 d Clindamycin, 300 milligrams four times a day for 10–14 d TMP-SMX, 160/800 milligrams twice a day Needle aspiration is first-line treatment. Obtain surgical consultation for treatment failure and multiloculated abscesses. Immunocompromised patients and those with signs of systemic illness require IV antibiotics, surgical consultation, and admission. Follow up with surgeon. Periductal mastitis Varies with age: Younger women—cellulitis or recur rent subareolar abscesses Perimenopausal and postmenopausal women—nipple discharge, nipple retraction, or subareolar mass Analgesia Antibiotics: Dicloxacillin, 500 milligrams four times a day for 10–14 d Cephalexin, 500 milligrams four times a day for 10–14 d Clindamycin, 300 milligrams four times a day for 10–14 d TMP-SMX, 160/800 milligrams twice a day Dilated or ectatic ducts with retained secretions. Follow up with surgeon. Hidradenitis suppurativa Painful superficial cutaneous abscesses along inferior, pendulous surface of breast Incision and drainage Chronic inflammatory disease involving the obstruction of sweat glands. Antibiotics may be indicated in immunocompromised patients. Abbreviation: MRSA = methicillin-resistant Staphylococcus aureus; TMP-SMX = trimethoprim-sulfamethoxazole. Tintinalli_Sec11_p0607-0668.indd 661 8/2/19 4:21 PM

breast Incision and drainage Chronic inflammatory disease involving the obstruction of sweat glands. Antibiotics may be indicated in immunocompromised patients. Abbreviation: MRSA = methicillin-resistant Staphylococcus aureus; TMP-SMX = trimethoprim-sulfamethoxazole. Tintinalli_Sec11_p0607-0668.indd 661 8/2/19 4:21 PM 662 SECTION 11: Obstetrics and Gynecology painful palpable cord or mass in the superficial tissue of the breast, most commonly in the lower quadrants. Skin discoloration, erythema, and nipple retraction may be present. Although the exact cause is unknown, trauma or a local inflammatory process has been linked to Mondor’s disease. US can establish the diagnosis of superficial thrombophlebitis. Treatment is nonsteroidal anti-inflammatory medication. Consider thrombophilic evaluation and treatment with low-molecular-weight heparins after hematology consultation. 20 Refer for appropriate follow-up.  NIPPLE IRRITATION Nipple irritation may be indicative of atopic dermatitis, erosive adeno matosis, or Paget’s disease. Erosive adenomatosis is a benign prolifera tion of the lactiferous ducts presenting with eczema or an erosion of the nipple. Referral to a breast specialist is needed for the latter condition because the treatment is surgical excision. Paget’s disease is often her alded by the appearance of a weeping, eczematoid lesion of the nipple. Paget’s disease is almost always associated with an underlying breast carcinoma and usually is diagnosed in postmenopausal women. Paget’s disease may present with an associated palpable breast mass, often cor relating with the presence of an intraductal carcinoma. Because skin edema and inflammatory changes may respond transiently to incor rectly prescribed topical treatments, there is usually a delay of 6 to 12 months in diagnosis. Provide urgent referral for bilateral mammog raphy and follow up with a breast specialist. FIBROCYSTIC DISEASE AND THE EVALUATION OF A BREAST MASS Fibrocystic breast disease is a constellation of symptoms linked by the pathognomonic finding of breast cysts. Breast nodularity and tender ness, which occur as a result of breast tissue responses to hormonal cycling, are referred to as fibrocystic breast disease or fibrocystic changes of the breast. Fibrocystic changes do not include skin thickening, edema, discoloration, nipple retraction, or discharge. If the history and physical examination findings in the ED are normal, then outpatient mammog raphy and follow-up with a specialist should occur, regardless of patient age. Further imaging, including additional mammography and MRI, may also be indicated. Women with recurrent or severe symptoms, skin changes, solid masses, nipple abnormalities, or anxiety about the pos sibility of cancer should be referred to a breast specialist. Breast cancer is rare in patients <20 years of age and uncommon in women <30 years of age. Risk factors for young women include inheritance of the BRCA1 or BRCA2 gene, a history of childhood malignancy, or a history of chest irradiation. A family history of a first-degree relative with breast cancer, increased exposure to endogenous estrogens (nulliparity or delay of childbearing until after age 30), or biopsyconfirmed atypical breast hyperplasia increases the risk for women ≥30 years old. However, most patients diagnosed with breast cancer have only two risk factors: age >50 years and female gender. Physical signs that should prompt urgent surgical referral include a palpable mass with or without the following: lymphadenopathy, skin ulceration, mass fixation to the chest wall, fixed axillary nodes, and the presence of ipsilateral arm edema.

breast cancer have only two risk factors: age >50 years and female gender. Physical signs that should prompt urgent surgical referral include a palpable mass with or without the following: lymphadenopathy, skin ulceration, mass fixation to the chest wall, fixed axillary nodes, and the presence of ipsilateral arm edema. Characteristics associated with a delayed diagnosis and poorer survival of breast cancer are black race, lower socioeconomic status, unmarried state, normal or false-negative mammogram results, presentation with nipple lesions or axillary mass, and younger age at time of diagnosis. 22-26 PERIOPERATIVE AND POSTOPERATIVE COMPLICATIONS  BREAST HEMATOMA Postoperative hemorrhage or expanding hematoma formation is best evaluated immediately and treated by the operating surgeon. Up to 1.5 L of blood can extravasate into traumatized breast parenchyma. Emergent evaluation requires determination of whether the hematoma is expanding, tensely distended, or stable. Expanding hematomas, especially those occurring within the first few postoperative days, may signify the presence of continued bleeding and usually require surgical evaluation for evacuation of the hematoma or ligation of bleeding vessels. Later presentations of breast hematoma are usually managed conservatively with analgesics, a compressive bra, and the correction of any coagulopathy. Aspiration of the hematoma generally is not effective in the ED. The presence of an infected hematoma requires inpatient management with US-guided percutaneous drainage or open surgical drainage; parenteral antibiotics generally are indicated.  WOUND INFECTION Postoperative wound infections may be treated with an oral firstgeneration cephalosporin on an outpatient basis if there is no evidence of abscess, systemic signs of toxicity, or immunocompromise. Worsen ing signs of cellulitis or systemic response to infection, development of purulent drainage, or failure to improve after 48 hours of treatment requires inpatient management. Infections of postoperative drains gen erally require drain removal and antibiotic therapy. Any fluid collections that develop subsequently usually require drainage either by repeated aspiration or by incision. The operating surgeon should be consulted regarding any postoperative complications.  BREAST IMPLANTS Approximately 3.5 million people in the United States have breast implants. Patients may present to the ED with complications such as implant rupture, hematoma, seroma, or infection. The risk of implant rupture increases with age but usually occurs after 20 years. Rupture is most commonly spontaneous, but may also be associated with blunt trauma. For saline implants, rupture is easily detected on physical exam by noting the deflated breast on the affected side. This is typically pain less, and outpatient follow-up is appropriate. Silicone implant ruptures are more difficult to diagnose on physical exam. US or MRI imaging confirms the diagnosis. Acutely ruptured silicone implants may pres ent with an inflamed, painful breast mass due to silicone extravasation. Although treatment involves surgical removal, patients should be reas sured that there is no danger from silicone leakage. 27,28 In the early breast implant postoperative period, complications such as seromas and hematomas may occur. Despite best practices, the rate of breast implant infections is about 6%, requiring readmission and additional surgery. Causative organisms are predominantly gram positive, with S. aureus being the most common agent. First-line treatment is vancomycin with gentamycin. For outpatient treatment, tetracycline and doxycycline are recommended. REFERENCES The complete reference list is available online at www.TintinalliEM.com.

tional surgery. Causative organisms are predominantly gram positive, with S. aureus being the most common agent. First-line treatment is vancomycin with gentamycin. For outpatient treatment, tetracycline and doxycycline are recommended. REFERENCES The complete reference list is available online at www.TintinalliEM.com. TABLE 104-3 Possible Causes of Different Types of Nipple Discharge Type of Discharge Cause Purulent Infection Periductal mastitis Milky (galactorrhea) Pregnancy Prolactinoma Pituitary adenoma or intracranial mass Drugs: hormones, psychotropics (phenothiazines), histamine-2 receptor antagonists, antiemetics (metoclopramide), antihypertensives (methyldopa, verapamil) Serous or serosanguineous Intraductal papilloma Ductal ectasia Cancer Watery Papilloma Cancer Green, gray, black, or tan Duct ectasia or periductal mastitis Tintinalli_Sec11_p0607-0668.indd 662 8/2/19 4:21 PM