Spontaneous perforation of pyometra resulting in generalized diffuse peritonitis is extremely uncommon. Herein, we report the case of a 63-year-old woman who presented to emergency department with a 2-day history of severe diffuse abdominal pain, high-grade fever, nausea, and vomiting. Acute abdomen series was done, and upright plain chest radiograph showed free air under diaphragm. A noncontrast-enhanced computed tomography scan showed a significantly distended fluid-filled uterus measuring 10 × 7.8 × 10 cm, in addition to a single focus of perforation involving the uterine fundus and associated with presence of free air within the nondependant area. No evidence of ascites or pelvi-abdominal lymphadenopathy was identified. A preoperative diagnosis of generalized peritonitis secondary to spontaneous perforation of uterus was established. Subsequently, patient underwent urgent exploratory laparotomy which revealed pus-filled uterus with perforated fundus. Diagnosis of generalized peritonitis secondary to spontaneous perforation of pyometra was established. Consequently, patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, as well as thorough drainage and irrigation of pelvi-abdominal cavity. Postoperatively, patient was admitted to intensive care unit. Histopathological examination of uterus was negative for malignancy, and surgical culture grew
Pyometra is defined as buildup of pus (purulent material) in the uterine cavity [
A 63-year-old woman presented to emergency department with a 2-day history of severe diffuse abdominal pain, high-grade fever, nausea, and vomiting. Patient was sexually active and denied any recent history of abnormal bleeding, spotting episodes, or vaginal discharges. Past medical history and surgical history were unremarkable. Systemic review was remarkable for decreased appetite and fatigue.
On physical examination, she looked ill and in pain. Her vitals were as follows: temperature of 38.7°C, blood pressure of 104/71 mmHg, heart rate (pulse) of 116 beats/minute, respiratory rate of 23 breaths/minute, and oxygen saturation of 97% in room air. Abdomen was slightly distended with positive guarding and positive rebound tenderness. Per vaginal examination showed no cervical/vaginal anomalies, vaginal discharge, or detectable pelvic mass. Initial laboratory results showed a white blood count (WBC) of 27 × 109/L (high neutrophilia), lactic acid of 2.1 mmol/L, and normal hepatic, coagulation, bone, renal, and electrolyte profiles.
Acute abdomen series was done, and upright plain chest radiograph (X-ray) showed free air (gas) under diaphragm (Figure
Upright chest plain radiograph (X-ray) showing free air (gas) under diaphragm.
Transverse (a) and sagittal (b) views of noncontrasted-enhanced computed tomography (CT) scan showing a significantly distended fluid-filled uterus measuring 10 × 7.8 × 10 cm, in addition to a single focus of perforation involving the uterine fundus and associated with presence of free air within the nondependant area. No evidence of ascites or pelvi-abdominal lymphadenopathy was identified.
Patient had an uneventful recovery afterwards and was discharged on the 15th postoperative day without complications.
Pyometra is defined as buildup of pus (purulent material) in the uterine cavity [
Pyometra primarily results from obstruction of cervical canal which in turn interferes with its natural drainage and increases susceptibility to infections leading to accumulation of pus and bloody material [
Potential predisposing risk factors for pyometra are numerous and include coexistence of comorbid chronic illnesses (e.g., diabetes, osteoarthritis), restricted mobility, bowel incontinence, malnutrition, poor hygiene, compromised immunity, excessive sexual activity, age-related genital tract atrophy, and uterine circulatory insufficiency—all of which lead to increased vulnerability to uterine infections and subsequent pus formation [
Determining the definitive diagnosis of pyometra preoperatively is largely difficult [
Spontaneous perforation of pyometra is exceedingly rare [
Definitive preoperative diagnosis of spontaneous perforation of pyometra is very infrequent [
Management of pyometra depends on the clinical setting (emergency or nonemergency) and status of pyometra (ruptured or nonruptured). Urgent and ruptured pyometra cases should be managed by total abdominal hysterectomy with bilateral salpingo-oophorectomy, thorough drainage and irrigation of pelvi-abdominal cavity, postoperative intensive care support, and administration of broad-spectrum antibiotics [
Pyometra, an extremely rare gynecologic condition, is defined as build up of pus (purulent material) in uterine cavity. Although exceedingly uncommon, spontaneous perforation of pyometra should be considered in the differential diagnosis of any elderly postmenopausal woman presenting with acute abdomen and signs of generalized peritonitis. Only around 50 case reports of spontaneous perforation of pyometra have been documented in the English literature so far. Urgent exploratory laparotomy is fundamental in confirming diagnosis and successfully managing patient. Abdominal hysterectomy with bilateral salpingo-oophorectomy, thorough drainage and irrigation of pelvi-abdominal cavity, postoperative intensive care support, and administration of broad-spectrum antibiotics is the mainstay of management in emergency settings. An underlying gynecologic malignancy is considerably high in pyometra and must be ruled out.
The authors sincerely acknowledge the editorial assistance of Ms. Ranim Chamseddin, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.