Pyometra: A Rare Cause of Acute Peritonitis

A 65-year-old female presented with acute-onset pain in abdomen for 2 d. The pain was localized initially to the lower abdomen but progressively became generalized. The pain was associated with nausea and abdominal distension. Her gynecologic history was unremarkable after having attained menopause at 48 y of age. She did not report any genital or urinary complaint. Physical examination revealed pulse rate of 130 beats/min, blood pressure of 100/60 mm Hg, and respiratory rate of 28 breaths/min. She was pyrexial and abdominal examination was consistent with generalized peritonitis. A chest radiograph showed free gas under the diaphragm. After resuscitation, the patient underwent exploratory laparotomy through midline vertical incision for suspected bowel perforation peritonitis. The surgical exploration revealed two liters of purulent fluid in the peritoneal cavity with apparently normal bowel, liver, and spleen. There was a perforation of size 1.5 cm present on the fundus of the uterus with necrotic margins. Pus was exuding from the perforation (Fig. 1). The diagnosis was spontaneous perforation of pyometra with acute peritonitis.

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FIG. 1.

Intraoperative photograph showing perforation in the fundus of the uterus.

Pyometra is defined as collection of pus within the uterine cavity and occurs usually in elderly post-menopausal women. The classic triad of symptoms in patients with pyometra consists of purulent vaginal discharge, post-menopausal bleeding, and lower abdominal pain. However, more than 50% of all patients with pyometra are asymptomatic [1]. Spontaneous perforation of pyometra is a rare complication that may masquerade clinically as acute bowel perforation. In a review of 18 cases of spontaneous perforation of pyometra, Nakao et al. reported that intra-abdominal gas was reported in 56% of patients, and concluded that spontaneous pyometra perforation should be considered in the differential diagnosis of peritonitis in elderly women [2]. Early diagnosis is important in initiating immediate treatment, thus reducing morbidity and mortality.

The common pathology resulting in pyometra is compromised natural drainage of the uterine cavity through a stenosed cervix. The cervical occlusion may be caused by malignant or benign tumors, radiation cervicitis, atrophic cervicitis, infection, or congenital anomalies [3,4]. The compromised drainage causes accumulation of secretions that may become infected and result in pyometra. Spontaneous perforation of the uterus may occur at a site of degenerative or necrotic change following development of pyometra and can cause generalized peritonitis [3].