Breast abscess is a limited inflammatory focus in the thickness of the soft tissues of the breast, which is an encapsulated purulent cavity. The disease develops and proceeds acutely, with a significant increase in temperature and intoxication phenomena, intense pain, redness and swelling of the breast, purulent discharge from the nipple. In the diagnosis, anamnesis and complaints data, objective examination and additional research methods (ultrasound of the breast, radiography, bacteriological seeding of the discharge from the breast) are important. Treatment of a breast abscess is only surgical (opening of the abscess) with parallel administration of antibiotics.
O91.1 Breast abscess associated with childbirth
Breast abscess is always a secondary pathology, which is a complication of a previously arisen breast disease (hematoma, mastitis and other purulent-inflammatory processes). The disease is more common in women, in 2% of cases it develops in nursing mothers, but it can also affect men, adolescents and newborns. Breast abscess associated with lactation occurs during the first six weeks after delivery. In newborns, purulent formations of the mammary glands develop at the age of 1-1.5 months. The abscess, as a rule, is formed on one side, bilateral abscesses are diagnosed extremely rarely, usually in infants.
Causes of breast abscess
The disease is caused by the penetration of pathogenic bacteria into the breast tissue (staphylococci, streptococci, proteus, E. coli or their associations). The melting of the gland tissue with the formation of a closed abscess occurs due to the following diseases:
- Mastitis. Occurs as a result of stagnation of milk in the breast. Inflammation of the mammary gland leads to an active multiplication of bacteria in its tissues, which in 6-11% ends with abscessing.
- Chest injury. Bruising of the breast is often accompanied by the formation of a hematoma. In the absence of treatment, the hematoma is suppressed and encapsulated.
- Galactophorite. This is an inflammation of the milk ducts, the most common cause of which is a breast injury. The disease refers to non-lactational mastitis.
- Cyst or benign tumor. Neoplasms squeeze the milk ducts, causing their blockage. As a result of the addition of a secondary infection, the formation of a closed purulent formation occurs.
- Hormonal failure. Hormonal disorders provoke stagnation of lymph and blood in the mammary glands, which activates the reproduction of pathogenic microflora. Hormone imbalance is observed in mastopathy, during the newborn period and in various endocrine pathologies.
- Purulent-inflammatory diseases. The cause of breast abscess may be the following diseases: furunculosis, axillary lymphadenitis, pyoderma, carbuncle. Pathogenic microbes penetrate hematogenically into the tissues of the mammary glands, cause an inflammatory process in them, followed by the formation of an abscess.
There are a number of predisposing factors, the presence of which increases the risk of developing the disease. These include weakened immunity, lactostasis, cracked nipples of the breast, smoking, endocrine diseases. Carrying out invasive medical manipulations (ductography, small surgical interventions on the breast), nipple piercing with non-compliance with aseptic conditions can contribute to the penetration of infection.
The entrance gate for infection is more often the nipple or its damaged areola. In some cases, infectious agents enter the mammary gland with blood flow from other purulent formations. Bacteria spread through the milk ducts in the tissues of the gland, begin to multiply actively, releasing toxins and decay products, which leads to the development of intoxication syndrome.
Inflammatory edema that occurs in the walls of the milk ducts is the result of an immune response to the action of bacterial antigens and causes microcirculation disorder. The permeability of the vascular wall increases, the intercellular fluid enters the lumen of the milk ducts, their blockage occurs. Lactostasis aggravates the inflammatory process in the milk ducts, which also spreads to the surrounding tissues. In the future, there is a melting of inflamed tissues, their separation from healthy ones by a dense capsule and the formation of a cavity containing pus.
In mammology, the generally accepted classification of breast abscesses is used. The systematization of purulent formations of the mammary gland is carried out according to their localization, the number of ulcers, the lesion of one or both glands. Depending on the location , there are:
- Subcutaneous abscess. It is located superficially, it is easily diagnosed due to the translucency of pus.
- Subareolar abscess. It is located under the nipple and its areola. It is more common in lactating women.
- Intramammary abscess. It is located in the thickness of the glandular tissue of the breast.
- Retromammary abscess. It is located between retro-mammary fatty tissue and pectoral muscles. The most dangerous form of the disease, representing a high risk of purulent melting of the muscles and the breakthrough of an abscess into the chest cavity.
Depending on the involvement of one or both mammary glands in the pathological process, unilateral and bilateral abscesses are distinguished. According to the number of ulcers in one gland, abscesses are divided into single and multiple.
Symptoms of breast abscess
The disease begins acutely, with a rise in temperature to 38-39 ° C. In the case of a previous breast injury, signs of a formed purulent formation appear on 3-5 days. Patients are concerned about sharp, throbbing pain in the mammary gland, redness of the skin over the purulent focus, its soreness during palpation. The pain in the gland increases when shaking in the car, walking and jumping.
When feeling the gland, you can accurately identify the epicenter of pain. The mammary gland swells, purulent discharge may appear from the nipple, often with blood clots. Axillary lymph nodes on the side of the lesion are enlarged in size and painful on palpation. Common signs of intoxication are added to local symptoms: nausea and vomiting, weakness, adynamia, lack of appetite, palpitations.
The leading symptoms depend on the location of the abscess. With a subareolar location of the purulent formation, there is an increase in the nipple and its areola due to edema. A dense and painful formation is palpated under the periarticular zone. When an intramammary abscess is located at an insignificant depth, there is a dense and hyperemic area at the site of its localization. In the case of a deep abscess, there are no external changes in the breast. If a retro-mammary abscess has formed, then the gland rises and takes the form of a hemisphere directed forward and upward.
The lack of timely treatment leads to the breakthrough of the abscess and the development of complications. With a superficial location of purulent formation, the probability of formation of a fistula is high. It is also possible to develop phlegmon of the mammary gland, the breakthrough of the abscess into the milky passages, followed by the release of milk with an admixture of pus and blood clots. The long-existing purulent inflammation in the milky ducts destroys their walls and causes metaplasia (degeneration) of epithelial cells, which is fraught with the formation of malignant processes. The most dangerous complication of breast abscess is the development of sepsis, in which bacteria with blood flow spread throughout the body, which leads to the formation of new multiple purulent foci in different organs and tissues.
Breast abscess is diagnosed by a mammologist or surgeon. The doctor finds out the anamnesis, clarifies the connection of the disease with lactation, decreased immunity or injury, examines the breast and reveals the characteristic signs of purulent formation: hyperemia of the skin, soreness and fluctuation of a certain area of the gland, enlarged axillary lymph nodes. Laboratory and instrumental research methods are also used in the diagnosis of breast abscesses:
- Clinical tests. In the peripheral blood, leukocytosis with a shift to the left is detected, acceleration of ESR (signs of inflammation), proteinuria and leukocyturia are possible in the urine.
- Bacteriological sowing of breast secretions. The nipple discharge or the contents of the abscess obtained by puncture are examined, the pathogen and its sensitivity to antibiotics are determined.
- Ultrasound of the breast. The localization, size, depth of location and number of ulcers, their communication with the milk ducts and with each other are specified.
- Mammography. It helps to determine the shape and size of the purulent formation, its approximate localization and to conduct differential diagnosis with non-inflammatory breast diseases.
- CT scan of the breast. It is irreplaceable in case of unsatisfactory results of mammography and ultrasound, in the presence of retromammary abscess and during differential diagnosis of purulent formation with other breast pathologies.
Differential diagnosis of breast abscess is carried out with phlegmon, hematoma, fibroadenoma, breast carcinoma, with fatty necrosis and a number of other diseases. For this purpose, a cytogram of the discharge from the nipple, a puncture of the formation and an analysis of the punctate, a biopsy of the suspicious area with subsequent histological examination is performed.
Treatment of breast abscess
The treatment of the formed abscess is based on emergency surgical intervention – opening of the abscess and its drainage. Incisions are made from the center (areola of the nipple) to the periphery (base of the gland). In some situations, it is more expedient to make an incision in the fold under the mammary gland. The wound is examined, all the detected ulcers are opened and connected into one cavity, the pus is removed and the wound is washed with an antiseptic solution. Then a drainage is installed and the wound is partially sutured.
Drainage is left in the wound for 3 to 4 days, until the discharge is stopped, after which the wound is sutured tightly. Puncture aspiration of pus from the abscess and the introduction of an antibiotic solution into its cavity is possible. Such an intervention is not traumatic and does not leave a scar after healing, but it is not effective enough. Puncture is performed only in the presence of a small single abscess.
In parallel with the surgical intervention, antibiotics are prescribed according to the sensitivity of the isolated pathogens (penicillins, cephalosporins, fluoroquinolones), infusion therapy is carried out for the purpose of detoxification. It is also indicated to take NSAIDs that eliminate pain, reduce fever and reduce signs of inflammation. In order to stimulate immunity, the use of immunomodulators is recommended.
Prognosis and prevention
With timely access to a doctor and adequate treatment, the prognosis is favorable. The function of the breast is restored completely, there are no consequences, except for the scar. Prevention of breast abscess during lactation consists in observing the rules of breastfeeding: full pumping of the mammary glands, taking air baths for the breast, washing the glands before and after feeding, prevention and timely treatment of cracked nipples, daily bra change. General preventive measures include a healthy diet, adherence to the daily routine and rest, detection and correction of endocrine disorders, rejection of bad habits and nipple piercing, strengthening immunity.