Clinical History
An HIV-positive 42-year-old female patient on antiretroviral therapy with past surgical history of laparoscopic myomectomy 3 weeks ago in Nigeria, presented to the Emergency Department febrile and complaining of lower abdominal pain. Thrombocytosis and neutrophilic leukocytosis was found on the complete blood count.
Imaging Findings
A contrast-enhanced CT in portal phase was performed and revealed an enlarged uterus with thickened walls and inner air-fluid level due to the purulent discharge occupying the uterine lumen (Fig. 1, 3)
A fistulous tract formation through the abdominal wall and subcutaneous cellular tissue of the umbilical region was identified (Fig. 1, 2) with surrounding fat stranding, inflammatory changes and moderate amount of free pelvic fluid.
Discussion
Pyometra is described as the accumulation of purulent material in the uterine cavity. According to the literature, the incidence fluctuates from 0.2 to 5% [1] and the main underlying mechanism is the blockade of the cervical canal due to cervicitis, puerperal infection or uterine surgery. Nevertheless, in postmenopaused women there is a strong association between pyometra and related malignancy and for this reason, a malignant neoplasm should always be ruled out in this age group [2]
Although more than 50% of the patients with non-ruptured pyometra are asymptomatic, the classic triad of lower abdominal pain, purulent vaginal discharge and postmenopausal bleeding should raise suspicion of pyometra. Other non-specific symptoms such as fever, vomiting and uterine enlargement are not uncommon [1-2]
Due to the vague symptoms and the high index of awareness required, perforated pyometras are usually misdiagnosed and treated as gastrointestinal perforation, with pneumoperitoneum being the main indication for exploratory laparotomy (97.5%) [3]. For that reason, pyometras are often diagnosed intra-operatively.
Either abdominal or transvaginal ultrasound as well as contrast-enhanced CT will greatly help the clinician to reach a proper diagnosis showing an uterine air-fluid level as well as thickening of the uterine wall with stranding and inflammatory changes of the adjacent fat. Furthermore, a varying amount of pneumoperitoneum will show up in those pyometras complicated with perforation. In our case, a transvaginal and abdominal ultrasound arose the suspicion of pyometra, which was definitely confirmed through the contrast-enhanced CT so our patient could benefit from an early diagnosis and immediate laparotomy, recovering completely.
With regard to the treatment, a pyometra should be always considered an abscess and must be treated promptly with proper drainage, broad-spectrum antibiotic coverage and evacuation of the uterine cavity. Additionaly, it has to be emphasised that in postmenopaused women the dilation of the cervical canal and posterior curettage will help to exclude any associated malignancy. On the other hand, ruptured pyometras should be approached with emergency laparotomy, irrigation of peritoneal cavity and simple histerectomy. [1]
The prognosis of pyometra is variable, being worse in those cases associated to malignancy as compared to the cases attributable to cervicitis, puerperal infection or uterine surgery. In both scenarios, perforation significantly worsens the prognosis as long as these patients develop easily generalised peritonitis and subsequent septic shock. [4]
Differential Diagnosis List
Fistulising pyometra post-myomectomy
Gastrointestinal perforation
Abdominal abscess
Uterine rupture
Fibroid degeneration
Senile cervicitis
Final Diagnosis
Fistulising pyometra post-myomectomy
