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Radiology of Infectious Diseases 5 (2018) 177e179
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Case Report

Postmenopausal pyometra related to forgotten intrauterine device

Besim Haluk Bacanakgil, Sezgi Güllü Yıldırım*
_
Istanbul Training and Research Hospital, Turkey
Received 10 December 2017; revised 19 January 2018; accepted 22 January 2018
Available online 31 January 2018

Abstract

Pyometra is an intrauterine abscess formation. It is a potentially lethal disease. In the postmenopausal patients, forgotten intrauterine device
(IUD) gives rise to pyometra. Sonography and computed tomography (CT) are required for the diagnosis. Drainage and uterine curettage after
dilatation are essential procedures. Antibiotics that are effective against both aerobic and anaerobic bacteria should be given patients.
© 2018 Beijing You’an Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Intrauterine device; Menopause; Pyometra

1. Introduction 2. Case

Pyometra is accumulation of pus in the uterine cavity due
to its natural drainage blockage [1]. Among gynecological
patients, the incidency is 0.03e0.11% [1,2]. In the post-
menopausal elderly patients, the incidency increases to 0.2%
[1]. Uterine corporal/cervical benign and malign tumors, ra-
diation cervicitis, atrofic cervical stenosis, congenital anoma-
lies and intrauterine devices (IUD's) are the etiological factors
[1e7]. In elderly, more than one factor could be present.
Forgotten IUD is an important predisposing factor for pyo-
metra in the postmenopausal patients [3e6], and 28.6% of the
pyometra cases are associated with IUD [6]. Pyometra could
be perforated spontaneously. It could be fatal by causing
peritonitis and sepsis. The ratio of spontaneous perforation of
pyometra is 6.7e18.5% [2e7]. Also, the ratio of the mortality
is 25% [8].
In this article, we aim to present non-perforated pyometra
related to IUD which is a rare condition that can cause severe
complications especially in elderly.
* Corresponding author.
E-mail address: yilsez@gmail.com (S.G. Yıldırım).
Peer review under responsibility of Beijing You'an Hospital affiliated to
Capital Medical University.
A 63-year-old, in postmenopausal period for 13 years,
woman applied to our policlinic with dark colored-malodorous
vaginal discharge, lower abdominal pain, nausea and pyrexia.
Lower abdomen was sensitive, and fever was 39
C. Uterus
was palpated as at 10 weeks size, soft and sensitive. At
transvaginal sonography, enlarged uterus with hypoechoic
fluid collection which containing hyperechogenic components
and IUD in uterine cavity were observed, and endometrial
structure was wholly loss (Figure 1). She told that she has IUD
for 15 years, and IUD's string could not be seen at speculum
examination. With these findings, patient was internated with
the diagnosis of pyometra. Laboratory findings were as
leukocyte 14.95  109/L (normal, 4.23e10.2), C-reactive
protein 16.45 mg/dL (normal, 0e0.5), sedimentation rate
81 mm/h (normal, 0e20), and biochemistry normal. At
computed tomography (CT), air-fluid level related to abscess
and at the same time IUD were determined (Figure 2). Under
the antibiotherapy (iv ceftriaxon þ metronidazole), cervix
uteri was dilatated, IUD (Cooper-T) was taken out, nearly
50 cc pus was drained, and uterus was curettaged. After one
week, recollection observed in the uterine cavity at sonogra-
phy. The collection was aspirated after cervical redilatation.
There was not microbiological growth at blood, IUD and pus
cultures. Histopathological examination of the currettage
material resulted as active chronic nonspecific endometritis.

https://doi.org/10.1016/j.jrid.2018.01.001
2352-6211/© 2018 Beijing You’an Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
178 B.H. Bacanakgil, S.G. Yıldırım / Radiology of Infectious Diseases 5 (2018) 177e179
Fig. 1. Transvaginal grey scala sonogram. IUD in enlarged uterine cavity
(arrow) and partly hyperechogen fluid collection.
Fig. 2. Contrast-enhanced pelvic axial CT scan. Intrauterine abscess formation
with air-fluid level and IUD in uterine cavity (white arrow). Linear calcifi-
cations within uterine wall (black arrow), (asterix ¼ bladder).
3. Discussion
The classical triad of pyometra is postmenopausal vaginal
bleeding, malodorous vaginal discharge and lower abdominal
pain [1e7]. At gynecological examination, uterus is enlarged,
soft and sensitive. IUD's string could not be seen due to breaking
or displacement to the intrauterine cavity in postmenopausal
patients. The clinical findings of pyometra are nonspecific.
Differential diagnosis should be made with pelvic inflammatory
disease, tuboovarian abscess, appendicitis and diverticulitis.
Sonography and CT are diagnostic tools for pyometra. At
sonography; enlarged uterus and intrauterine hypoechogen
fluid collection which had hyperechogenic components are
seen [5,6]. IUD can be observed in cavity. Mostly, endometrial
structure is not observed. If the uterus is not perforated, pelvic
free fluid could not be seen. CT findings are enlarged uterus
with low attenuated abnormal fluid collection (±air-fluid
level), linear calcifications (which allows the distinction be-
tween pyometra and distended bladder) caused by athero-
sclerotic vessels within uterine wall and mural air which sign
for endometrial necrotizan suppurative inflammation on uter-
ine wall [5,6,9e11]. IUD can be seen in uterine cavity. In our
patient's transvaginal sonography and CT, we also found the
findings related to pyometra.
In postmenopausal period, IUD should be withdrawn from
the uterus. Forgotten or long time rest IUD cause to severe
infections and inflammations [3e6,12]. These infections and
inflammations could be presented as pelvic inflammatory
disease, tuboovarian abscess, endometritis and pyometra.
Especially, the risk of infection is high in patients with >5
years IUD [13,14].
The isolated bacterias from the cultures are usually
Escherichia coli and Bacteriodes fragilis. 8e17% of the cul-
tures are sterile [1,8]. Also, in 5.5% of the cultures from IUD
may not be growth [15]. All cultures were sterile in our patient.
Pyometra is an abscess formation, and drainage should be
performed immediately. Under the broad-spectrum iv anti-
biotherapy, cervical dilatation and drainage plus curettage are
the main treatment [1,2,7,8]. Pyometra could be repeated or
persisted at the ratio of 33% [2]. After the first intervention,
the patients should be called to control.
Consent-ethical statement
Written informed consent was obtained from the patient for
the publication of this report and any accompanying images.
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