top of page

Breast Engorgement vs Mastitis vs Breast Abscess: What PLAB 2 Doctors Must Know

Breast complaints are common in postpartum women, and PLAB 2 often tests your ability to differentiate between benign and serious causes of breast pain — especially in breastfeeding mothers.

In this blog, we’ll simplify the key differences, pathophysiology, and management of breast engorgement, mastitis, and breast abscess — all in line with what PLAB 2 examiners expect from you.


🧠 Understanding the Basics

Let’s start with a quick definition:

Condition

Definition

Breast Engorgement

Overfilling of the breasts with milk, causing pain and swelling. Not infected.

Mastitis

Inflammation of breast tissue, often due to infection. Can be infective or non-infective.

Breast Abscess

A pus-filled collection in the breast, usually resulting from untreated or poorly managed mastitis.


🧬 Pathophysiology – What's Going On Inside?

Understanding why each condition occurs helps guide diagnosis and treatment.


🔹 Breast Engorgement

  • Occurs in early postpartum when milk production exceeds removal.

  • Causes swelling, pressure, and pain due to milk stasis and edema.

  • Triggered by poor latch, infrequent feeding, or sudden weaning.


🔸 Mastitis

  • Often starts as engorgement or blocked duct.

  • Milk stasis allows bacteria (commonly Staphylococcus aureus) to grow.

  • Entry via nipple cracks leads to inflammatory and infective response.


🔻 Breast Abscess

  • A complication of mastitis, especially if untreated.

  • The infection becomes walled off, forming a localized pus collection.

  • Requires drainage and antibiotics.


🔍 Clinical Features – Spot the Differences!

Feature

Engorgement

Mastitis

Abscess

Onset

Gradual

Sudden

Gradual or sudden

Pain

Dull, full, heavy

Localized, burning

Severe, throbbing

Redness

Mild or absent

Present

Present, may be more marked

Fever

No

Yes

Yes

Breastfeeding

Painful but should continue

Painful but recommended

Usually not possible from affected side

Lump

Diffuse fullness

Localized tender area

Fluctuant lump

Systemic symptoms

Absent

Fever, chills, malaise

Fever, fatigue

Laterality

Usually bilateral

Usually unilateral

Unilateral

Nipple discharge

Only milk

Possibly purulent

May have pus



🛠️ Management – What Should You Do?


✅ Breast Engorgement

  • Encourage regular breastfeeding or expression

  • Warm compress before feeds, cold compress after

  • Breast massage during feeds

  • Supportive, non-restrictive bra

  • No antibiotics required

  • Refer to breastfeeding support if latch issues suspected

  • Follow-up in 24–48 hours

  • Safety net: Return if fever, increasing pain, or redness


⚠️ Mastitis

  • Continue breastfeeding or expressing

  • Pain relief: Paracetamol or ibuprofen

  • Antibiotics if:

    • Symptoms >24 hours

    • Systemically unwell

    • Signs of infection (fever, redness, purulent discharge)

  • First-line: Flucloxacillin 500mg QDS for 10–14 days

  • Erythromycin if penicillin allergy

  • Refer to lactation support

  • Follow-up in 48 hours

  • Safety net: Watch for signs of abscess


❗ Breast Abscess

  • Urgent referral to surgical team or breast clinic

  • Ultrasound to confirm abscess

  • Incision and drainage or needle aspiration

  • Antibiotics as per mastitis

  • Do not breastfeed from affected side if too painful, but continue on other side or express

  • Follow-up for wound care and re-evaluation


📚 PLAB 2 OSCE Tips

✅ Always start by confirming identity and elaborating on the complaint.✅ Rule out differentials: Mastitis, Abscess, and rarely Malignancy in older women.✅ Ask about breastfeeding habits, latch, nipple trauma, fever, and systemic symptoms.✅ Be empathetic: New mothers are often anxious.✅ Explain in simple terms what’s going on inside the breast.✅ Offer leaflets, refer to breastfeeding support teams, and safety net clearly.


📌 Final Thoughts

In PLAB 2, you’ll be expected not just to recognize the condition, but to manage it safely, supportively, and with clear communication. Differentiating these three conditions is critical:

  • Engorgement is painful, but not dangerous — treat with feeding advice.

  • Mastitis needs antibiotics if symptoms persist or worsen.

  • Abscess is a surgical emergency — don’t delay referral.


📚 References

bottom of page