Spontaneous rupture of pyometra - a rare cause of peritonitis in elderly female

Generalized peritonitis secondary to spontaneously perforated pyometra in elderly women:two cases with different clinical courses and surgical approaches and review of the literature

We describe two cases of spontaneously perforated pyometra (SPP) in elderly women treated with two different surgical approaches. An 88-year-old woman underwent emergency laparotomy for presumed diagnosis of gastrointestinal (GI) tract perforation. During surgery, SPP and a tumor of the sigmoid colon were identified. Total hysterectomy and sigmoid colon resection were performed. Despite exhaustive postoperative treatments, the patient died on postoperative day (POD) 189 due to peritonitis and pneumonia. A 93-year-old woman with acute abdomen was diagnosed with severe pyometra and primarily treated with transcervical drainage. Due to progression of generalized peritonitis, laparoscopic surgery was performed. Intraoperatively, scar from a uterine body perforation was identified, leading to the diagnosis of SPP. Only peritoneal irrigation and drainage were performed, in consideration of her advanced age. She improved and was discharged from the hospital on POD 35. The prognosis for SPP is sometimes poor, especially in older women. Minimally invasive surgical intervention might be considered for primary treatment in such cases.

Spontaneous perforation of pyometra presenting as acute abdomen and pneumoperitoneum mimicking those of gastrointestinal origin

Gastrointestinal (GI) perforation accounts for over 90% of acute abdomen and pneumoperitoneum. The presence of pneumoperitoneum secondary to spontaneously perforated pyometra is an interesting yet confusing finding given the absence of gastrointestinal (GI) perforation, because pyometra is more common in postmenopausal women. We report an instructive case of diffuse peritonitis caused by spontaneous perforation of pyometra. A 70-year-old postmenopausal female was admitted to surgical emergency with signs of diffuse peritonitis. After resuscitation, an emergency laparotomy was performed because of suspicion of GI perforation. At laparotomy, about 2,000 mL of purulent fluid was found to be present in peritoneal cavity, while GI tract was intact. A rent with a diameter of 5 mm was found on anterior fundus of uterus. A total abdominal hysterectomy with a bilateral salpingo-oophorectomy was performed. Despite intensive care and a course of antibiotics, the patient died of multiple organ failure resulting from sepsis on postoperative day 16. Our case illustrates the importance of clinical knowledge of acute gynecological diseases, which are not uncommonly encountered by the general surgeon. Moreover, good appreciation of pelvic anatomy and close collaboration with gynecology and GI surgery colleagues is essential as operative intervention is often required.

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.