Male Nipple Pain: Causes, Evaluation, and When to See a Doctor

Common Causes of Nipple Pain in Men

• Hormonal fluctuations: Pubertal gynecomastia (transient), aging-related testosterone decline, elevated estradiol (obesity, liver disease, medications).
• Gynecomastia: Benign glandular proliferation; often bilateral, tender. Causes: medications (spironolactone, finasteride, cimetidine, anabolic steroids, some antipsychotics), hyperthyroidism, renal/liver failure, testicular tumors.
• Trauma/friction: Sports (runner's nipple), tight clothing, direct blow.
• Infection: Mastitis, abscess (rare in men); fungal (intertrigo).
• Dermatitis: Contact (detergents, fabrics), atopic, psoriasis.
• Medication side effects: SSRIs, SNRIs, digoxin, calcium channel blockers, prostate drugs.
• Paget's disease of the nipple: Rare adenocarcinoma; unilateral eczematous changes, discharge, ulceration. Must biopsy.
• Breast cancer: Rare (<1% of breast cancers); presents as painless lump, but can cause nipple retraction, discharge, skin changes.

Evaluation

1. History: onset, duration, laterality, associated symptoms, medications, supplements, trauma.
2. Exam: breast/nipple inspection, palpation for masses, lymph nodes.
3. Imaging: Diagnostic mammogram + ultrasound (if mass/suspicious findings).
4. Labs: Testosterone, estradiol, prolactin, TSH, LFTs if indicated.
5. Biopsy: For persistent unilateral changes, suspicious imaging.

When to See a Doctor

• Persistent (>2 weeks) or worsening pain
• Unilateral symptoms
• Palpable mass, skin changes, nipple discharge (especially bloody)
• Associated systemic symptoms

Treatment

Target underlying cause: medication adjustment, hormonal treatment, topical steroids for dermatitis, antibiotics for infection, surgery for gynecomastia/cancer.