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Clinical presentation of canine pyometraand mucometra: A review
S.D. Pretzer*
 Abilene Animal Hospital, P.A., 320 NE 14th Street, Abilene, KS 67410, USA
Abstract
Cystic endometrial hyperplasia (CEH) in the bitch can result in either pyometra, hematometra, or hydrometra, and many facetsof these uterine diseases can make them difficult to differentiate. The conditions differ in their systemic effects, since pyometra,particularly closed-cervix pyometra, can be a life-threatening condition that must be recognized, managed, and treatedexpeditiously. Mucometra is an accumulation of sterile intraluminal mucoid fluid, hematometra is an accumulation of sterile,bloody fluid, and hydrometra is an accumulation of sterile, watery fluid; none of which have any significant systemic outwardclinical signs. This paper will describe the definitions, signalment, historical findings, incidence, clinical signs, physical examfindings, and diagnostic findings in canine pyometra and mucometra, and hematometra and hydrometra.
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2008 Elsevier Inc. All rights reserved.
Keywords:
Pyometra; Mucometra; Cystic endometrial hyperplasia; CEH; Uterus
1. Introduction
Canine pyometra is a disease of intact bitches that isof particular importance to the veterinary practitioner,since early recognition, diagnosis and appropriateintervention is required to avoid disastrous conse-quences. Closed-cervix pyometra is particularly dan-gerous, because septicemia and toxemia may developrapidly and left untreated can result in patient death.Although mucometra, hematometra, and hydrometraby themselves are not fatal diseases, they must bedifferentiated from pyometra. Several diagnostic aidsare available to assist in diagnosing and differentiatingpyometra, mucometra, hematometra, and hydrometra.For the purposes of this discussion, the conditions of hematometra and hydrometra can be used interchange-ably with mucometra, unless otherwise noted.
2. Definition
Pyometra, by definition, is the accumulation of purulent material within the uterine lumen of intactbitches, typically occurring during or immediatelyfollowing a period of progesterone dominance. Histori-cally, it has been thought subacute endometritis isfollowed by cystic endometrial hyperplasia (CEH)which then predisposes bitches to develop pyometra[1,2]. Others suggest that, due to differences in clinicalandhistopathologicfindings,CEHandpyometrashouldbe classified separately[3]. It is common to seepyometradefinedastheendometritis/cysticendometrialhyperplasia/pyometra complex (CEH/P)[4]. Pyometrais classically a disease of the diestrual bitch and can beclassified as open-cervix or closed-cervix, with thelatter being a medical emergency requiring rapidintervention to prevent subsequent sepsis and potentialpatient death[5]. Mucometra, hematometra, or hydro-metra are thought to occur with CEH, and the character
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Theriogenology 70 (2008) 359–363* Tel.: +1 785 263 2301; fax: +1 785 263 2925.
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2008 Elsevier Inc. All rights reserved.doi:10.1016/j.theriogenology.2008.04.028
 
of the intrauterine fluid differs from pyometra in thatthey are classically all sterile and are the fluid isseromucous, bloody, or serous, respectively[3].
3. Signalment and history
Pyometra typically affects mature bitches that haveundergonerepeatedestrouscycling,withareportedmeanageof7.25years[6].Reportedagesforbitchesdiagnosedwithpyometrarangefromasyoungas4monthstoasoldas 16 years of age[7–16]. In a group of 192 bitches thatwere treated medically for pyometra, the mean agereported was 2.4 years[17]. Historical events of importance in evaluation of a diestrual, intact bitch forpyometra include prior treatment with estrogens orprogestins, whelping history, and date of last estrouscycle. There appears to be an increased incidence of pyometra in both nulliparous bitches and bitches greaterthan 4 years of age[18]. Prior reviews indicate thatnulliparous bitches comprise approximately 75% of thebitches with pyometra[1,8]. Hormonal therapies thatinclude either progestins for estrus suppression or estro-gens for estrus induction or pregnancy termination mayexplain the development of pyometra in young bitches[12,19,20].Youngbitcheswithanatomicabnormalitiesof the vagina and vestibule, such as strictures and septums,may be predisposed to develop these conditions.Some breeds reported to be predisposed to pyometrainclude the Rottweiler, Saint Bernard, Chow Chow,Golden Retriever, Miniature Schnauzer, Irish Terrier,Airedale Terrier, Cavalier King Charles Spaniel, RoughCollie, and Bernese Mountain dog[5,21]. Breeds with alowriskforpyometraincludeDrevers,GermanShepherddogs, Daschunds, and Swedish hounds[22]. Otherstudies have shown no breed disposition[9,12].Most bitches present with pyometra within 12 weeksafter the onset of the previous estrus, with a reportedmean of 5.7 weeks. However, pyometra may occur atany stage of the estrous cycle or during pregnancy[6].Nearly three-fourths of bitches in another studypresented within 8 weeks of completion of the priorestrus[23]. No association has been shown betweenfalse pregnancy and pyometra[13]. Pyometra shouldalways be considered in the differential diagnoses of any intact bitch presenting with malaise or illness, dueto the potential for life-threatening disease.
4. Incidence
Reportedincidencesfor pyometra include 9%[9]and15.2%[24], whereas another study found an incidenceof 2% in bitches greater than 10 years of age[22].The incidence of mucometra is largely unknown, asthe condition is usually an incidental finding duringovariohysterectomy or ultrasound examination of thereproductive tract. However, 13% of uteri in one studywerefoundtohaveeithermucometraorhydrometra[25].
5. Pathogenesis
Cystic endometrial hyperplasia develops afterrepeated progestational stimulation during the lutealphaseoftheestrouscycle[1].AlthoughCEHisgenerallythoughttopredisposethebitchtodeveloppyometra[1,2],the two conditions can develop independently of oneanother[3]. Furthermore, CEH is also associated withmucometra[7], as CEH can result in endometrialthickening with the accumulation of viscid fluid in theuterus. The main difference between mucometra andpyometra is that with mucometra the fluid accumulatingin the uterus is sterile and with pyometra, it is contami-nated with bacteria. During diestrus, a time of progester-one dominance in the bitch, progesterone increasesendometrial gland secretory activity, increases endome-trial proliferation, decreases myometrial contractility,and causes closure of the cervix[7]. These effects arecumulative after repeated estrous cycles, explaining theincreased incidence in middle-aged to older bitches.Estrogen stimulation prior to progesterone dominance isalso a component of the pathogenesis, although experi-mental exposure of the endometrium to estrogen alonecauses no specific pathologic change[8,26].Suppression of cellular immunity results fromincreasing progesterone concentration in the earlyluteal phase[27]. The combination of reduced localimmunity and favorable uterine conditions for patho-gens (increased glandular secretions and decreasedmyometrial activity) make bacterial colonization morelikely during this phase. The most common bacteriaisolated in cases of pyometra is
Escherichia coli
[7,25,28]which is also usually found in the feces of affected bitches[29]. Bacterial contamination of theuterus likely occurs prior to diestrus when the cervix isopen, and in cases of CEH, the bacteria cannot becleared prior to the luteal phase, leaving opportunisticorganisms in a prime environment for colonizationand proliferation.
E. coli
is a particularly dangerousorganism in cases of pyometra, due to endotoxin releasewhich may result in septic shock [30,31].
6. Clinical signs and physical exam findings
Clinical signs of pyometra in dogs depend primarilyonwhetherthecervixispatentenoughtoallowdrainage
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of purulent fluid. The most common clinical finding inbitches with open-cervix pyometra is a malodorous,sanguinous to mucopurulent vaginal discharge[14,17].Bitches with open-cervix pyometra are generally lesssystemically ill than bitches with closed-cervix pyome-tra and early in the course ofthe disease affected bitchesmay show no clinical signs other than vaginal discharge[1,7–9]. Additional clinical findings may includelethargy, depression, inappetance/anorexia, polyuria,polydipsia, vomiting, and diarrhea[12].In contrast, bitches with closed-cervix pyometra aregenerally very ill at presentation, with marked clinicalsigns of depression, lethargy, polyuria, polydipsia,vomiting, diarrhea, and possibly abdominal distension.Affected bitches are often dehydrated and septicemic,toxemic, and in shock. Fever may be present in bitcheswith pyometra, but those with toxemia may actually behypothermic[7–9]. There is typically no evidence of vulvar discharge.Pyometra causes varying degrees of systemic illness,but mucometra typically does not cause obviousclinical signs. Both entities can cause palpable uterineenlargementdue tofluidaccumulation.Inpyometra,thesize of the uterus is inversely proportional to the degreeof cervical patency[8]. Care should be practiced whenpalpating for suspected pyometra to avoid uterinerupture. Uncomplicated CEH and mucometra may onlycause the outward sign of failure to conceive, due to theabnormal endometrium[32].
7. Diagnostic findings
7.1. Clinical pathology
Cytologic examination of vaginal discharge is aninitial and very helpful tool in diagnosing caninepyometra and in differentiating open-cervix pyometrafrom mucometra. Neutrophils which are often degen-erative and present in large numbers are frequently seenon cytologic examination of vaginal discharge withpyometra.Intra-andextracellularbacteriamaybeseenincytologic specimens. With mucometra, cytology mayreveal lesser numbers of neutrophils, with or withoutdegenerative changes, red blood cells, endometrial cells(usuallywithfoamycytoplasm),andvarying amountsof amorphous debris. With hydrometra, scant red bloodcells and white blood cells, moderate numbers of endometrial cells,minimalmucusandamorphousdebrisare evident. With hematometra, red blood cells are thepredominant cell type, with scant white blood cells andminimal to moderate mucus, scant endometrial cells andminimal to moderate amorphous debris present.A common pathologic clinical finding in bitcheswith pyometra is a peripheral leukocytosis, which ismore pronounced in closed-cervix pyometra[33,34].When a differential cell count is performed, a leftshift is also a common finding[9,12,15]. Anormocytic, normochromic anemia may be seen incases of pyometra[7–12], with packed cell volumesranging from 21 to 48%[10]. Abnormalities in serumchemistry include azotemia, hypergammaglobuline-mia, and hypoalbuminemia[6]. Metabolic acidosis isa common finding[35–37]. Urinalysis findings areless consistent, as dehydration affects urine specificgravity. Decreased urine specific gravity has beenreported in approximately 20% of cases of pyometra[7]. Specific renal abnormalities have been describedin pyometra[7,38], including the decreased ability of the renal tubules to concentrate urine as a result of the effects of endotoxin, which accounts for both thedecreased specific gravity and the clinical signs of polyuria and polydipsia. Proteinuria may be obser-ved[7,39]. With mucometra, the serum chemistry,leukogram and urinalysis are typically withoutabnormality, except for a possible mild, regenerativeanemia.
7.2. Diagnostic imaging
The diagnosis of pyometra is best made with theaid of ultrasonography[40], and findings typicallyinclude an enlarged uterus with convoluted, tubularhorns filled with anechoic to hypoechoic fluid[41,42]. The luminal contents are usually homo-genous, but the contents may also be echodense withslow, swirling patterns[43]. A thickened endome-trium with cystic structures is diagnostic for CEH[41], with or without pyometra. Endometrial edemamay be present. Mucometra or hematometra aresuspected if uterine luminal contents are echodenceand hydrometra is suspected it luminal contents areanechoic in combination with a lack of clinical signsconsistent with pyometra[44]. Radiography may alsobe used as an aid in diagnosing pyometra in the bitch,but can be frequently inconclusive. The normalnonpregnant and early pregnant uterus are of soft-tissue or fluid radiopacity[45–47]. Other uterineconditions that have similar soft-tissue radiographiccharacteristics are pyometra, mucometra, and uterinetorsion[45–49]. These pathologic conditions of theuterus cannot be differentiated from early pregna-ncy in the bitch until fetal mineralization takesplace, which is approximately 45 days after ovulation[46].
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