Pyometra in A Postmenopausal Women: A Case Report

Rosalina, Amir Fauzi

Department of Obstetric and Gynaecology
Faculty of Medicine Sriwijaya University
dr. Mohammad Hoesin Hospital Palembang
Abstract
Pyometra is an uncommon disease, it refers to accumulation of purulent material
in the uterine cavity. Its reported incidence is 0.01-0.5% in gynecologic patients.
Mostly occurs at postmenopausal women. First case of pyometra was reported by
John and Clarke in London at 1812. The most common cause of pyometra is
malignant disease of genital tract and the consequences of their treatment
(radiotherapy). Other causes are benign tumor like leiomyoma, endometrial
polyps, senile cervicitis, cervical occlusion after surgery, puerperal infections, and
congenital cervical anomalies. The classic symptoms of pyometra (lower
abdominal pain, purulent vaginal discharge, and enlarged of uterus) are
nonspecific and frequently misdiagnosed by other cause of acute abdomen.
We present a case of pyometra in a 60 year old postmenopausal women, presented
with acute abdominal pain. Emergency explorative laparatomy was performed
under the diagnosis of torsion of the ovarian cyst. Total hysterectomy with
bilateral salphingo-oophorectomy was performed. Histopathologic result revealed
an endometritis caused by fungal infection. Culture of pus from uterine cavity
grew Pseudomonas cepacia.
Key words: Pyometra, postmenopausal women, acute abdomen, endometritis
INTRODUCTION
Pyometra is an uncommon disease, it refers to accumulation of purulent material
in the uterine cavity. Its reported incidence is 0.01-0.5% in gynecologic patients.
Mostly occurs at postmenopausal women. First case of pyometra was reported by
John and Clarke in London at 1812. The most common cause of this condition is
interference with the normal drainage of the uterus by malignant disease. Other
causes are benign tumor like leiomyoma, endometrial polyps, senile cervicitis,
cervical occlusion after surgery or irradiation, puerperal infections, and congenital
cervical anomalies. The classic symptoms of pyometra (lower abdominal pain,
purulent vaginal discharge, and enlarged of uterus) are nonspecific and frequently
misdiagnosed by other cause of acute abdomen. Spontaneous rupture of the uterus
is rare, but may occur following the formation of pyometra.

CASE REPORT
A 60 year old postmenopausal women, presented with lower abdominal pain of 1
week duration. The pain became severe one day before she was admitted to our
hospital. The menopause had occurred at the age of 46 years. She had no history
of postmenopausal bleeding or vaginal discharged, but she had suffered from
rheumatoid arthritis and for several years had been taking non steroid anti
inflammatory drugs dan corticosteroid.
On the physical examination, she looked moderately ill: her blood pressure
was 120/80 mmHg, pulse rate 98 beats/min, and axillary temperature was 37,9 0C.
Her abdomen was soft and not distended, bowel sounds were normal. Pelvic
examination revealed a cystic mass, diameter 10x8 cm with adhesion. The uterine
corpus at normal range, and parametrium was tender.
The results of laboratory studies on admission were as follows: white blood
cell count 19500/mm3 with 84% segs, sedimentation rate 95 mm/hr, and
hemoglobin 9,8 g/dL. Pelvic ultrasound revealed a cystic mass, diameter 10x8 cm,
hipoechoic, monoloculare, with thick wall; uterine was could not be identification.
The conclusion was ovarian cyst.
Emergency explorative laparotomy was performed under the diagnosis of
torsion of the ovarian cyst. Intra operatif, there was adhesion of the uterus with
adjacent structure. The uterus was soft and enlarged, and was found to have a
necrotic area at fundal. At the time of exploration, necrotic area became perforated
and about 500 cc of purulent material excluding. The fallopian tubes and ovaries
were normal. A total abdominal hysterectomy and bilateral salphingooophorectomy were performed. Culture of the pus grew Pseudomonas cepacia
that sensitive to cefepime, cotrimoxazole, and sulfonamide. Histological
examination revealed an endometritis and myometritis caused by fungal infection,
no evidence of malignancy.
Postoperatively, intensive intravenous antibiotic therapy with
Sulperazone and metronidazole was performed for 3 days,

continued with oral antibiotic. She recovered well and was

discharged on the 8th postoperative day.
DISCUSSION
Pyometra, or pyometrium, is defined as the accumulation of pus in the uterine
cavity resulting from interference with its natural drainage. Pyometra is common
in postmenopausal women, and more than 50% of all patients of nonruptured
pyometra are asymptomatic. The incidence of pyometra becomes much higher
with age and decline in activity. Postmenopausal bleeding, vaginal discharge,
uterine enlargement, and cramping pain are said to be the classic symptoms of
pyometra, only bleeding and discharge were commonly reported in these cases but
this patient had no vaginal bleeding or discharge.
Various malignant and benign diseases have been shown to cause pyometra.
The most common cause of pyometra is malignant disease of genital tract and the
consequences of their treatment (radiotherapy). Other causes are benign tumor
like leiomyoma, endometrial polyps, senile cervicitis, cervical occlusion after
surgery, puerperal infections, and congenital cervical anomalies. A detailed pelvic
examination should be performed to rule out the associated malignancies.
Histological examination of the uterus in our case revealed no evidence of
malignancy, myomata or other abnormality adjacent to the site of the rupture.
Long term steroid therapy would however have predisposed her to infection
which may have caused the tissues to become more friable as the infection
invaded the myometrium
The diagnosis of pyometra is difficult, because it is usually asymptomatic.
Ruptured pyometra should be kept in mind in elderly women presenting with
acute abdomen as an unusual but serious condition.