Rare cause of acute surgical abdomen with free intraperitoneal air: Spontaneous perforated pyometra. A report of 2 cases

Spontaneous perforation of pyometra: A rare cause of acute abdomen and sepsis

Pyometra, the accumulation of purulent material in the uterine cavity, is a rare gynecological condition whose etiology is impaired drainage of the uterine cavity. It is uncommon in premenopausal age and occurs mainly in older and postmenopausal women. Clinical signs of pyometra are vaginal discharge, postmenopausal bleeding, and lower abdominal pain. An 87-year-old woman was admitted to our emergency department with abdominal pain, fever, and vomiting. The results of physical examination revealed rebound tenderness and muscular rigidity in the lower abdomen. Ultrasonography demonstrated free fluid in the abdomen, and percutaneous aspiration revealed that this fluid was purulent. A computed tomography scan showed a large amount of free fluid in the abdominal cavity and a uterine myoma. The patient underwent emergency laparotomy due to acute abdomen. During the laparotomy, a 2×1 cm perforation was seen at the fundus of the uterus. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. A culture of the pus grew Escherichia coli. Histopathological examination revealed degenerative uterine myoma with no evidence of malignancy. Pathological results indicated myometrial suppurative inflammation along with neutrophilia and necrosis. Pyometra is a rare event; however, it must be considered when investigating acute abdomen etiology. Because pyometra involves abscess formation, drainage and evacuation of the uterine cavity while leaving a drain in the cavity and dilating the cervical canal is the main treatment protocol. In cases of perforation, hysterectomy is the treatment choice; however, with concomitant diseases in older patients, immediate surgery is related to important morbidity and mortality risks.

A Case Report and Literature Review of Spontaneous Perforation of Pyometra

BACKGROUND

Pyometra is defined as an accumulation of purulent material in the uterine cavity. Spontaneous perforation is a very rare complication of pyometra. The clinical findings of perforated pyometra are similar to perforation of the gastrointestinal tract and other causes of acute abdomen.

CASE REPORT

We report a rare and difficult case of peritonitis in an elderly female that was caused by a spontaneous perforation of pyometra. A 90-year-old postmenopausal woman was referred to our hospital with complaints of vomiting, fever, and abdominal pain. Computed tomography revealed a large amount of ascites, cystic mass in the uterus, and intraperitoneal and intrauterine air. Transvaginal ultrasound demonstrated a thin area around the fundus. An emergency laparotomy was performed for the suspected gastrointestinal perforation or perforation of pyometra. At laparotomy, copious purulent fluid was present in the peritoneal cavity; however, no perforation of the gastrointestinal tract was observed. We identified a perforation site over the uterine fundus and purulent material exuding from the cavity. Subsequently, hysterectomy and bilateral salpingo-oophorectomy were performed. The patient was discharged on postoperative day 13 with no complications. Histopathologic studies revealed endometritis and myometritis with no evidence of malignancy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With diffuse peritonitis, ruptured pyometra should be considered, even in elderly female patients. This case illustrates the importance of clinical knowledge of acute gynecologic diseases. Here we also review the perforation of pyometra with no evidence of malignancy.

Spontaneous Rupture of Pyometra Causing Peritonitis in Elderly Female Diagnosed on Dynamic Transvaginal Ultrasound

Pyometra is collection of pus within the uterine cavity and is usually associated with underlying gynaecological malignancy or other benign causes. Spontaneous rupture of pyometra is a rare complication. We report a case of a 65-year-old female who presented with acute abdomen and was diagnosed with a ruptured uterus secondary to pyometra and consequent peritonitis on dynamic transvaginal sonography (TVS) which was later confirmed on contrast enhanced computed tomography (CECT). An emergency laparotomy was performed and about 800 cc of pus was drained from the peritoneal cavity. A rent was found in the anterior uterine wall and hence hysterectomy was performed. Histopathology revealed mixed inflammatory cell infiltrate with no evidence of malignancy. There are only 31 cases of ruptured pyometra reported till date, most of which were definitively diagnosed only on laparotomy. In only two of these cases the preoperative diagnosis was made on CECT. We report this case, as the correct and definitive diagnosis was made preoperatively on dynamic TVS. To our knowledge, this is the first case report revealing spontaneous ruptured pyometra being diagnosed preoperatively on dynamic TVS. This report is aimed at giving emphasis on the use of simple dynamic TVS for accurate diagnosis of rare spontaneous ruptured pyometra causing peritonitis.

Spontaneous uterine perforation caused by pyometra: a case report

Introduction:

Pyometra is an accumulation of purulent material or pus in the uterine cavity. Spontaneous perforation of uterus by pyometra is rare. This is a clinical presentation and management of a spontaneous perforation of uterine caused by pyometra.

Case Presentation:

This is a case report on spontaneously perforated associated with pyometra secondary to cervical malignancy. The patient underwent exploratory laparotomy with total hysterectomy and bilateral salpingo-oophorectomy.

Conclusions:

Spontaneous rupture of pyometra duo to cervical cancer in cases of acute abdomen in elderly patients should be considered.

Spontaneous uterine perforation of pyometra presenting as acute abdomen

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.