# Spontaneous Uterine Perforation of Pyometra Presenting as Acute Abdomen

Authors: Toshihiro Kitai; Kentaro Okuno; Hiromi Ugaki; Yoshiko Komoto; Satoshi Fujimi; Masahiko Takemura
Journal: Case Reports in Obstetrics and Gynecology
 (2014)

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## Abstract

Pyometra is the accumulation of pus in the uterine cavity, and spontaneous perforation of pyometra resulting in generalized diffuse peritonitis is extremely uncommon. We report a rare case of diffuse peritonitis caused by spontaneous perforation of pyometra. A 66-year-old postmenopausal woman with diffuse abdominal pain and vomiting was admitted to our institution. She had a history of mixed connective-tissue disease and had been taking steroids for 20 years. Under a diagnosis of generalized peritonitis secondary to perforation of the gastrointestinal tract or uterus, supravaginal hysterectomy and bilateral salpingo-oophorectomy were performed. Unfortunately, wound dehiscence and infection occurred during the postoperative course, which were exacerbated by her immunocompromised state. Despite intensive care and a course of antibiotics, the patient died of multiple organ failure resulting from sepsis on the 36th postoperative day. Although correct diagnosis, early intervention, and proper treatment can reduce morbidity and mortality of spontaneous perforation of pyometra, if severe infection occurs, this disease can be life threatening for immunocompromised hosts.


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## Body

## 1. Introduction

Pyometra is the accumulation of pus in the uterine cavity resulting from interference with its natural drainage [1], which may or may not be associated with malignancy. As an uncommon condition, it has been reported to occur in 0.1-0.2% of all gynecologic patients and 13.6% of elderly gynecologic outpatients [2]. Pyometra develops gradually and, as it progresses, may enlarge the uterus, causing degenerative changes that may rarely lead to sloughing of the uterine wall with subsequent spillage of contents into the abdominal cavity [3]. Spontaneous perforation of pyometra resulting in generalized diffuse peritonitis is very rare. To date, about 50 case reports of spontaneous perforation of pyometra have been documented in the English literature. This paper reports an additional case of spontaneous uterine perforation of pyometra.


## 2. Case Presentation

A 66-year-old multiparous postmenopausal woman was admitted because of diffuse abdominal pain and vomiting during the previous 24 hours. She had history of mixed connective-tissue disease and had been taking steroids for 20 years. In addition, she had received hemodialysis for chronic renal failure dating from 2 months previously. Her gynecologic history was unremarkable, and there was no history of postmenopausal bleeding or vaginal discharge. On physical examination, she appeared ill, with vital signs as follows: body temperature 37.3°C, blood pressure 96/61 mmHg, pulse rate 82 beats/min, and oxygen saturation 96% (oxygen mask 4 L/min). Her abdomen was distended, with tenderness in the lower portion. Vaginal examination showed no cervical and vaginal anomalies, vaginal discharge, or detectable pelvic mass. Results of laboratory investigations on admission were as follows: white blood cell (WBC) count 3.0 × 103/μL, hemoglobin 11.3 g/dL, and C-reactive protein (CRP) 7.32 mg/dL. Progression to sepsis was suspected because the WBC count documented at the previous institution was 13.0 × 103/μL, a drastic decline. A contrast-enhanced computed tomography (CT) scan showed the presence of fluid within the abdominal cavity and a significantly distended fluid-filled uterus. In addition, free air was detected in the abdominal and uterine cavities (Figure 1).Figure 1
Transverse view of contrast-enhanced computed tomography scan showing the presence of fluid within the abdominal cavity and a significantly distended fluid-filled uterus. In addition, free air was detected in the abdominal and uterine cavities. White arrow indicates the perforation site.A preoperative diagnosis of generalized peritonitis secondary to perforation of the gastrointestinal tract or uterus was established. Consequently, emergent laparotomy was performed. At laparotomy about 300 mL of seropurulent, fluid was encountered in the peritoneal cavity. No abnormal findings were found in the gastrointestinal tract; however, a perforation with a diameter of 1 cm was found in the uterine fundus. The fallopian tubes and ovaries were normal. A supravaginal hysterectomy and bilateral salpingo-oophorectomy were performed (Figure2).Figure 2
The resected corpus of the uterus. White arrow indicates the perforation site.Culture of the pus grewKlebsiella pneumoniae,Escherichia coli, andBacteroides fragilis. Histologic examination revealed pyometra with no evidence of malignancy. Cervical cytology performed after surgery was negative for intraepithelial lesion or malignancy.Figure3 shows the postoperative course. The patient was admitted to the intensive care unit with strict management of respiration and circulation. Under antibiotic therapy with doripenem (750 mg/day, daily administration), her condition improved over time and she was transferred to the gynecology unit on postoperative day (POD) 8. However, she broke into high fever on POD 9. Antibiotics were changed from doripenem to micafungin (75 mg/day, daily administration) because the culture of her sputum grewCandida albicans and β-d-glucan was increased in the blood. Subsequently, wound dehiscence occurred, and secondary wound closure was performed on POD 11. She was transferred to the intensive care unit again after surgery, and vancomycin (500 mg/day, alternate-day administration) was added to antibiotic therapy because methicillin-resistantStaphylococcus aureus was detected from wound culture. From POD 11, high fever continued and platelet count declined once again. Although hepatic and renal dysfunctions were not revealed, sepsis and multiple organ failure were suspected. Despite the readministration of doripenem, thromboses of the inferior vena cava caused by infection and cerebral infarction were found on POD 26. Although antibiotics were changed from doripenem to linezolid (600 mg/day, daily administration) or vancomycin, sepsis grew progressively worse. Despite exhaustive clinical efforts, the patient died on POD 36.Figure 3
Postoperative course. BT: body temperature; WBC: white blood cell count; Hb: hemoglobin; Plt: platelet; CRP: C-reactive protein; DRPM: doripenem; MCFG: micafungin; VCM: vancomycin; LZD: linezolid.


## 3. Discussion

Pyometra is rare in the general population but more common in elderly women. It is caused as a result of occlusion of the cervical canal by malignant or benign tumors, surgery, radiotherapy, or senile cervicitis [11]. Pyometra is a difficult diagnosis. The classic triad of symptoms is postmenopausal bleeding, vaginal discharge, and lower abdominal pain, but none of these is specific for pyometra and some patients have no symptoms at all [29]. Spontaneous perforation of pyometra is no less rare. To date, only 50 case reports have been documented in the English literature.A PubMed literature search using key words such as “pyometra,” “perforation,” and “rupture” was performed, and only English-language articles were collected. Table1 summarizes the 42 cases of spontaneous perforation of pyometra during the past decade, from 2004 to 2013, including our case. The median age was 75 years (range, 40–93). The common clinical symptoms were abdominal pain (41 cases, 97.6%), fever (23 cases, 54.8%), and vomiting (13 cases, 31.0%). No case had genital bleeding and five cases (11.9%) were in shock at the time of admission. Data regarding the associated malignancy were available in all 42 cases. Of the 11 cases (26.2%) with malignant tumor, eight (72.7%) had cervical cancer and three (27.3%) had sigmoid colon cancer. Although preoperative diagnosis was confirmed in all 42 cases, an accurate preoperative diagnosis was made in only 13 cases (30.9%). The other preoperative diagnoses included perforation of the gastrointestinal tract in 20 cases (47.6%), generalized peritonitis in five cases (11.9%), appendicitis in one case (2.4%), pneumoperitoneum in one case (2.4%), mesenteric artery ischemia in one case (2.4%), and incarcerated hernia in one case (2.4%). The low preoperative diagnostic rate suggested that preoperative diagnosis of spontaneous perforation of pyometra was difficult. Laparotomy was performed in all 42 cases as an initial treatment. Total, subtotal, or supravaginal hysterectomies were performed in 37 cases (88.1%), drainage in four cases (9.5%), and surgical closure of perforated uterine wall in one case (2.4%). Data regarding the perforation site were available in 35 cases. The sites of uterine perforation were the fundus in 27 cases (77.1%), anterior in five cases (14.3%), and posterior in three cases (8.6%). Bacteriological studies of peritoneal pus were performed in 25 cases. The common etiological organisms wereEscherichia coli (10 cases, 40.0%) andBacteroides species (five cases, 20.0%). The other bacteria wereKlebsiella,Streptococcus,Staphylococcus,Acinetobacter,Porphyromonas,Enterococcus, andActinomyces species. No bacteria were detected from the culture in four cases (16.0%). Data regarding complicated diseases were available in 29 cases. Nine cases (31.0%) involved an immunocompromised state, such as renal failure, diabetes mellitus, and steroid administration. The prognoses were documented in 33 cases. The total number of patients who died was five (15.2%). Of those in an immunocompromised state, four patients died, or the mortality rate was 44.4%. This may suggest that immunocompromised hosts represent a group at high risk for spontaneous perforation of pyometra. It is hoped that further cases are accumulated and that statistical analysis is performed.Table 1
Cases of spontaneous perforation of pyometra from the literature review and our own case.
Patients
First author
Age
Symptoms
Preoperative diagnosis
Associated malignancy
Perforation site
Bacterial culture
Treatment
Immunocompromised state
Outcome
1
Nuamah [4]
79
AP, F, and V
PGIT
None
Fundus
ND
TAH + BSO
ND
Died (MOF)
2
Shahid [5]
80
AP
PGIT
CC
Fundus
ND
TAH + BSO
ND
Survived
3
Chan [6]
73
AP, shock
PP
None
Fundus
Klebsiella pneumoniae, Streptococcus viridans
TAH + BSO
DM
Survived
4
Tsai [7]
40
AP, F
GP
None
Fundus
ND
STH
ND
Survived
5
Yildizhan [8]
92
AP, V
PGIT
None
Fundus
Escherichia coli, Bacteroides fragilis
TAH + BSO
ND
Survived
6
Geranpayeh [9]
63
AP, F, and V
PGIT
None
ND
Negative
TAH + BSO
ND
Survived
7
Lee [10]
60
AP, F
PGIT
CC
Fundus
B. fragilis
TAH + BSO
DM, RF
ND
8
Saha [3]
60
AP
PGIT
None
Fundus
Staphylococcus aureus
SVH + BSO
ND
Survived
9
Li [11]
69
AP, F, and V
PGIT, GP
None
Anterior
B. fragilis
SVH + BSO
None
Survived
10
Vyas [12]
60
AP, V
PP
CC
Fundus
Acinetobacter species
Drainage
ND
Survived
11
Izumi [13]
83
AP
PP
None
Fundus
Bacteroides distasonis, Porphyromonas asaccharolytica, and Streptococcus oralis
TAH
None
Survived
12
Ou [14]
78
AP, F
PGIT
SCC
ND
ND
TAH + BSO
ND
ND
13
54
AP, F
Pneumoperitoneum
None
ND
ND
TAH + BSO
ND
ND
14
78
AP
PP
CC
ND
ND
TAH + BSO
ND
ND
15
80
AP
PGIT
CC
ND
ND
Drainage
ND
ND
16
73
AP, F
PP
CC
ND
ND
TAH + BSO
ND
ND
17
81
AP, F
GP
None
ND
ND
TAH
ND
ND
18
Kim [15]
80
AP
PP
None
Fundus
ND
TAH + BSO
None
Survived
19
Chen [16]
68
AP, F
PGIT
SCC
Fundus
ND
TAH + BSO + OME
ND
Survived
20
Agarwal [17]
60
AP, F
PGIT
CC
Fundus
ND
Drainage
ND
Survived
21
Stunell [18]
64
AP
PP
None
Fundus
ND
TAH + BSO
None
ND
22
Lim [19]
89
AP, F
GPIT
None
Fundus
E. coli
TAH + BSO
None
Survived
23
87
AP
GPIT
None
Fundus
Enterococcus faecalis
Surgical closure
None
ND
24
Chaopotong [20]
88
AP, F, and V
GP
None
Fundus
Negative
TAH + BSO
DM
Died (sepsis)
25
Sahoo [21]
50
AP, F, and shock
GPIT
None
Fundus
ND
TAH + BSO
ND
Survived
26
Shapey [22]
84
AP, V
GPIT
None
Anterior
Negative
TAH
Steroid administration
Survived
27
Ikeda [23]
80
AP
PP
CC
Anterior
E. coli
TAH + BSO
None
Survived
28
81
AP, F
PGIT
None
Fundus
E. coli
TAH + BSO
None
Survived
29
93
AP, F
PGIT
None
Posterior
K. pneumoniae, Enterococcus faecalis, and Streptococcus species
TAH
None
Survived
30
84
AP
PGIT
SCC
Anterior
E. coli
TAH + BSO
None
Survived
31
74
AP, F
PP
None
Fundus
E. coli, Staphylococcus epidermidis
STH + BSO
None
Survived
32
79
AP, F
Appendicitis
None
Fundus
E. coli
TAH
None
Survived
33
66
Shock
PP
None
Anterior
K. pneumoniae
Drainage
DM
Died (strangulation ileus)
34
Kutuk [24]
71
AP, F, and V
GP
None
Fundus
E. coli
TAH + BSO
ND
Survived
35
75
AP, V
Mesenteric artery ischemia
None
Fundus
Negative
TAH + BSO
None
Survived
36
68
AP
GPIT
None
Posterior
E. coli
TAH + BSO
RF
Died (sepsis)
37
Hagiya [25]
86
AP, shock
PP
None
Fundus
Actinomyces species
TAH + BSO
DM
Survived
38
Mallah [26]
78
AP, F, and V
Incarcerated hernia
None
Fundus
ND
TAH + BSO
None
Survived
39
61
AP, F, V, and shock
GP
None
Posterior
ND
TAH + BSO
None
Survived
40
Abu-Zaid [27]
63
AP, F, and V
PP
None
Fundus
Streptococcus constellatus
TAH + BSO
None
Survived
41
Patil [28]
74
AP, F
PGIT
None
Fundus
ND
TAH + BSO
DM
Survived
42
Kitai [present case]
66
AP, V
PP
None
Fundus
E. coli, B. fragilis
SVH + BSO
RF, steroid administration
Died (sepsis)
AP: abdominal pain; F: fever; V: vomiting; PGIT: perforation of the gastrointestinal tract; PP: perforation of pyometra; GP: generalized peritonitis; CC: cervical cancer; SCC: sigmoid colon cancer; TAH: total abdominal hysterectomy; STH: subtotal hysterectomy; SVH: supravaginal hysterectomy; BSO: bilateral salpingo-oophorectomy; DM: diabetes mellitus; RF: renal failure; MOF: multiple organ failure.


## 4. Conclusion

Although correct diagnosis, early intervention, and proper treatment can reduce morbidity and mortality of spontaneous perforation of pyometra, if severe infection occurs, this disease can be life threatening for immunocompromised hosts.



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*Source: 738568-2014-06-24.xml*