Pyometra

Pyometra is a collection of pus in the uterine cavity, usually from infection behind a blocked cervical canal.

• It is most common in postmenopausal women, in whom cervical stenosis, cervical or endometrial cancer, or radiotherapy is the cause.
• Other causes are a retained intrauterine device, postpartum or postabortal infection and endometritis.
• It can cause sepsis and uterine perforation.

Lower abdominal pain, fever, purulent or blood-stained discharge (absent if the canal is closed), a tender enlarged uterus, and sometimes postmenopausal bleeding.

• Elderly women may be confused or have minimal fever.
• Differential diagnosis: haematometra, endometrial cancer, cervical cancer, pelvic abscess, tubo-ovarian abscess, fibroid, ovarian tumour.
• Complications: sepsis, septic shock, uterine perforation with peritonitis, pelvic abscess, and an underlying cancer in some cases.

Diagnosis is by ultrasound, with drainage of pus and biopsy to exclude cancer.

• Speculum examination for cervical stenosis or purulent discharge.
• Transvaginal or abdominal ultrasound showing a fluid-filled cavity with debris or gas.
• CT scan or MRI for suspected cancer or perforation.
• Full blood count, C-reactive protein, blood cultures, urea, creatinine and lactate; culture of the drained pus.
• Biopsy of the endometrium and cervix after drainage to exclude cancer.

Give IV antibiotics, drain the pus, and exclude an underlying cancer.

• Supportive: IV access and fluids; analgesia; oxygen; monitoring of vital signs and urine output; sepsis bundle if shock.
• Pharmacological: ceftriaxone 1 g IV daily plus metronidazole 500 mg IV 8-hourly until afebrile for 24 to 48 hours, then amoxicillin-clavulanate 625 mg oral 8-hourly to complete 7 to 10 days. Alternative: ampicillin 2 g IV 6-hourly plus gentamicin 5 mg/kg IV once daily (maximum 480 mg) plus metronidazole 500 mg IV 8-hourly. Septic shock: 30 mL/kg crystalloid, then noradrenaline if blood pressure stays low. Paracetamol 1 g IV or oral 6-hourly (maximum 4 g in 24 hours).
• Procedures: cervical dilatation and drainage of pus under ultrasound guidance with a Foley catheter or drain left in the cavity for 24 to 48 hours; gentle technique to avoid perforation; endometrial and cervical biopsy at drainage; laparotomy for perforation or generalised peritonitis; hysterectomy with bilateral salpingo-oophorectomy for recurrent pyometra, cancer or failed drainage.
• Special groups: in elderly women reduce gentamicin by renal function or choose ceftriaxone plus metronidazole; monitor fluid balance for heart failure. In women with an intrauterine device, remove it at drainage.
• Red flags: hypotension, confusion, peritonism, free fluid on ultrasound, lactate above 2 mmol/L, suspected cancer.
• Follow-up: review at 1 week and 6 weeks; repeat ultrasound; histology results at 1 week; hysterectomy if recurrence occurs.