CASE STUDY- ENDOMETRIAL PYOMETRA

INTRODUCTION
Pyometra is an accumulation of large quantities of purulent exudate in the uterus
causing its distention (Hughes et al. 1979). It must be distinguished from the smaller,
intermittent accumulations of fluid that can be detected by ultrasonography in
acute endometritis. It occurs because of interference with natural drainage of fluid
from the uterus, which may be due to cervical adhesions or an abnormally constricted,
tortuous, or irregular cervix. In some cases, the fluid accumulates in the absence of
cervical lesions, presumably due to an impaired ability to eliminate the exudate; due
to some genital tract malignancy, mainly squamous cell carcinoma of the
endometrium, impairment in the natural drainage through cervix due to stenosis or
neoplasms and the consequences of radiotherapy. Other causes are foreign bodies,
puerperal infections or uterine anomalies.

Pyometra is an uncommon result of endometritis. The diagnosis of pyometra is made

when a collection of pus is found within the endometrial cavity. It has been reported
that pyometra has an incidence of less than 1% of gynaecologic patients. The
incidence of pyometra increases with age and is 13.6% in elderly patients. The
median age of presentation as postulated by Chauhan, S. C. A., et al. (2015); is 65
years and less than one-third are associated with underlying malignancy. The typical
symptoms of pyometra include uterine enlargement, cramping, vaginal discharge,
acute abdominal pain, and postmenopausal bleeding (Jones, V. A. at al, 1986).

Case Presentation: A 53 year old black African postmenopausal lady of Para 4

Gravida 5 aborta 1 presented to the Oncology Ultrasound Department with a history
of diagnosed cervical carcinoma stage at TNM (T-primary tumour; N-regional lymph
node; M-metastasis) stage 1B revealed on abdominal Multi-Detector Computed
Tomography (MDCT). The CT scan had revealed a cervical cystic mass and dilatation
of left intrahepatic ducts in February 2022. Upon this diagnosis, she received a local
small field irradiation dose to the cervical cancer over ten days after which she was
discharged. She then visited the department in April complaining of drowsiness, loss
of appetite, complaining of non foul smelling discharge and abdominal fullness.
Transabdominal ultrasound findings were of a hypoechoic cervical solid mass of 4.6
cm x 4.01 cm and anechoic endometrial free fluid giving a diagnosis of cervical
carcinoma and hydrometra. She was treated on albothyl suppositories and oral
antibiotics as an outpatient. On 01 August 2022, she presented to the Oncology
Ultrasound Department for ultrasound examination of the pelvis. On physical
examination, her uterus was enlarged about 15 weeks of gestation, she was afebrile,
no fever, complaining of loss of appetite, general body malaise, had foul smelling
purulent discharge and anaemic.

INDICATION
Postmenopausal purulent vaginal discharge.
Date Of Examination: 01 August 2022

PATIENT INFORMATION

Date of Birth: 16 May 1969

Parity: 4
Gravida: 5
Aborta 1
LMP: 8 years ago
Hormonal therapy Nil
Current medication Albothyl suppositories
Radiotherapy treatment Small field irradiation dose for ten days on
cervical cancer
Marital status: Married
Sex: Female
Level of Education: Ordinary Level

EQUIPMENT
Mindray DC-8 Ultrasound machine.
3.5-5MHz curvilinear probe .
Sony High glossy thermal paper.
Ultrasound gel.
Sony Ultrasound Printer.
PATIENT PREPARATION, PATIENT CARE AND PROTOCOL
Standard Gynaecological Transabdominal Scan Protocol documented in appendix A
attached.

OBSERVATIONS AND FINDINGS

 The uterus was enlarged, anteverted, non- gravid, non fibroid and measured 10.60
cm x 6.32 cm x 9.32 cm with an inhomogeneous echotexture. There was an
anechoic fluid collection in the endometrial cavity resulting in marked distention.
 The myometrium was hypoechoic.
 The anechoic endometrial fluid demonstrated posterior enhancement and a
volume of 44.43 cc (4,74x3.11x5.77) cm, thus a dilated fluid filled endometrial
cavity was demonstrated.
 A bulky cervix measuring 5.05 cm x 4.38 cm with an echogenic solid mass was
seen. There was no vascularity seen on color Doppler interrogation.
 Both ovaries were not visualised.
 The adnexae were seen clear of any cystic or solid masses.
 There was no free fluid in the pouch of Douglas and the immediate pelvic region.
 The urinary bladder was partially distended, volume of 94.33 ml (6.18 x 6.23 x
4.68) cm with anechoic urine free of calculi and urinary bladder masses.

COMMENT
 The endometrial free fluid collection of volume 44.43cc is suggestive of
haematometra, hydrometra or pyometra. A provisional diagnosis of endometrial
pyometra was made on the basis of the foul smelling purulent fluid vaginal
discharge seen on physical examination.
 An echogenic cervical mass confirms the previous Multi-Detector Computed
Tomography (MDCT) diagnosis of cervical carcinoma.
 Differential diagnosis: Endometritis, hydrometra or haematometra.
 Recommend cervical dilatation under anaesthesia to obtain pus sample for culture
(laboratory tests).
 Clinical correlation highly advised.
DISCUSSION
Pyometra in postmenopausal females as postulated by Lui, M. W. et al. (2015), is due
to obstruction in drainage of the uterine cavity or a natural drainage impairment
within the cervix, often attributed to a structural process (e.g. cervical stenosis),
benign or malignant pathology, or secondary to radiotherapy. Additionally, urogenital
anomalies, namely atrophic cervicitis, have reportedly contributed to the disease’s
manifestation.

The main causes are malignant diseases of the genital tract and its treatment like
radiotherapy associated cervical stenosis; senile cervicitis, endometritis, cervical
stenosis after surgery, cervical leiomyoma and congenital cervical anomalies
(Mackowiak, P. A. 2006). Similarly, the diagnosis of pyometra in this case was made
basing on the clinical symptom of foul-smelling vaginal discharge and sonographic
appearance of intrauterine fluid collections. In addition, there was an intrauterine
echogenic cervical mass with sonographic features suggestive of cervical carcinoma
presumably causing obstruction in drainage of the uterine cavity often attributed to a
structural process (e.g. cervical stenosis), secondary to radiotherapy.

Characteristically, the symptoms of pyometra include postmenopausal bleeding,

purulent, vaginal discharge and uterine enlargement although they can also be
relatively non-specific. After menopause, when endometrium loses its resistance – not
shed repeatedly, infection which gains entrance to uterus persists as senile
endometritis. The pus which tends to collect in uterus forms pyometra, as cervix is
narrowed by senile change and atrophied myometrium unable to expel it. Ultrasound
is used in most cases for primary diagnoses but sometimes CT, MRI and Doppler
scanning for excluding malignancy like endometrial cancer are necessary modalities.

In the presenting case, abdominal Multi-Detector Computed Tomography (MDCT)

revealed a cervical cystic mass diagnosed as cervical carcinoma stage at TNM (T-
primary tumour; N-regional lymph node; M-metastasis) stage 1B. Following this
staging and diagnosis of the cervical carcinoma, radiation therapy was initiated
together with antibiotics. revealed on abdominal Multi-Detector Computed
Tomography (MDCT). The diagnosis of pyometra should be considered when elderly
women suffer from acute lower abdominal pain. Remarkably, there was an underlying
malignancy, structural deficit, clinical and physical signs/symptoms to account for the
pyometra.

MANAGEMENT
Drainage of pus by repeat dilatations, usually under anaesthesia by putting a Foley’s
catheter/drainage tube followed by curettage under antibiotic is the preferred choice
or route for primary treatment. Thus, the appropriate management of patients with
suspected pyometra should comprise cervical dilatation to drain the pus, together with
antibiotics. Performing hysteroscopy in the presence of pyometra is potentially
dangerous and should be contraindicated because the infected material inside the
uterine cavity may disseminate into the peritoneal cavity via the fallopian tube during
hysteroscopy, resulting in peritonitis and septicaemia(Loffer, F. D. 1995).

CONCLUSION
Pyometra is a collection of purulent fluid within the uterine cavity. Cervical stenosis
most frequently involves the internal os. The acquired causes of cervical stenosis
include infection, neoplasia, and iatrogenic factors (radiation therapy or surgery).
Pyometra is an uncommon, but important gynaecologic condition, because the
incidence of the association with malignant disease is considerable, and spontaneous
rupture can result in significant morbidity and mortality. Dilatation of the cervix and
pus drainage is the treatment of choice, and it is important to rule out the possibility of
cancer and differentiate the malignancy.

Ultrasound has significant clinical utility and Doppler imaging is also beneficial,
particularly in evaluating blood flow changes associated with an inter-current
endometrial cancer. In persistent cases of pyometra, repeat drainage is indicated;
conversely, if the condition is intractable, definitive surgical management is
recommended, particularly when conservative measures have been exhausted or an
underlying malignancy cannot be excluded. Finally, routine surveillance is warranted
to promptly detect or avert substantial haemorrhaging, uterine rupture and peritonitis,
all of which may significantly increase the incidence of patient morbidity and
mortality.
REFERENCES:

1. Chauhan, S. C. A., Sharma, L. C. M. M., and Banerjee, B. J. K. (2015):

Spontaneous Perforation Of Pyometra: a Rare Cause Of Diffuse Peritonitis. Med J
Armed Forces India. 2015;71:192–3.
2. Loffer, F. D. (1995): Contraindications And Complications Of Hysteroscopy.
Obstet Gynecol Clin North Am 1995; 22: 445–55.
3. Lui, M. W., Cheung, V. Y. and Pun, T. C. (2015): Clinical Significance Of
Pyometra. J Reprod Med 2015; 60: 329-32.
4. Mackowiak, P. A. (2006): An Elderly Woman With Pain And Fever. CID.
2006:1218–9.