{"paper_id":"007df2fa-5cd5-43ef-8e8b-f896387abdce","body_text":"Received\n 06/08/2024 \nReview began\n 07/07/2024 \nReview ended\n 07/11/2024 \nPublished\n 07/20/2024\n© Copyright \n2024\nDhabalia et al. This is an open access\narticle distributed under the terms of the\nCreative Commons Attribution License CC-\nBY 4.0., which permits unrestricted use,\ndistribution, and reproduction in any\nmedium, provided the original author and\nsource are credited.\nDOI:\n 10.7759/cureus.64973\nA Rare Case of Pyometra in a 65-Year-Old Post-\nmenopausal Woman\nRishabh Dhabalia \n, \nPratapsingh Parihar \n, \nShivali V. Kashikar \n, \nSuhit Naseri \n, \nShakti Sagar \n1.\n Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (DMIMS), Wardha,\nIND \n2.\n Pathology, Datta Meghe Institute of Medical Sciences (DMIMS) School of Epidemiology and Public Health,\nWardha, IND \n3.\n Pathology, Datta Meghe Institute of Higher Education and Research, Wardha, IND\nCorresponding author: \nRishabh Dhabalia, \nrishabhssj05@gmail.com\nAbstract\nPyometra is a gynecological condition characterized by pus accumulation in the endometrial cavity. It is a\nrare condition, and it should be included in the differential diagnosis of abdominal pain in postmenopausal\nwomen. We present a case of a 65-year-old postmenopausal woman with complaints of foul-smelling white\ndischarge, itching in the perineal region, lower abdominal pain, and postmenopausal bleeding for two to\nthree months. USG of the pelvis was done outside, which revealed heterogeneous ill-defined cervical growth\nwith endometrial fluid collection and multiple uterine fibroids. CT and MRI of the pelvis were done in our\nhospital, which revealed an ill-defined heterogeneously enhancing growth in the cervix with multiple\nuterine fibroids and heterogeneous endometrial collection showing restricted diffusion in MRI suggestive of\npyometra. Cervical biopsy revealed features suggestive of moderately differentiated squamous cell\ncarcinoma.\nCategories:\n Pathology, Obstetrics/Gynecology, Radiology\nKeywords:\n intrauterine infection, mri, endometrial collection, postmenopausal, pyometra\nIntroduction\nPyometra is a rare gynecological condition defined as an accumulation of purulent fluid within the\nendometrial cavity \n[1,2]\n. Pyometra develops as a result of increased production of progesterone. Increased\nprogesterone production leads to cervical canal enlargement, allowing local microorganisms to migrate\nretrogradely through the cervix from the vagina into the uterine cavity \n[3]\n. The most common risk factors\ninclude post-surgical, post-intrauterine device (IUD) placement or removal, post-partum, and post-\nmenopausal women \n[4]\n. The causes of pyometra include cervical or uterine malignancy, endometrial polyps,\nendometritis/pelvic inflammatory disease, cervical stenosis (most commonly post-operative), and structural\nanomalies (imperforate hymen) \n[1,5]\n. Patients usually present with post-menopausal bleeding, white\ndischarge, fever, and abdominal pain. Some patients might even be asymptomatic \n[6]\n. The overall incidence\nof pyometra is very low, i.e. <0.01 %. This manuscript describes a case of a 65-year-old postmenopausal\npatient with pyometra.\nCase Presentation\nA 65-year-old female patient presented with a history of excessive, foul-smelling white discharge from the\nvagina, itching over the perineal region, lower abdominal pain, and postmenopausal bleeding for two to\nthree months. Her general and systemic examinations were within normal limits. Her per-vaginal\nexamination revealed an endophytic cervical growth involving the anterior vaginal wall and parametrium\nbilaterally. Her per-speculum examination revealed fragile necrotic cervical growth, which bled on touch\nwith foul-smelling discharge.\nHer pelvic ultrasound examination was done outside, which revealed heterogeneous ill-defined cervical\ngrowth with endometrial fluid collection and multiple uterine fibroids. CT abdomen-pelvis (Figure \n1\n) and\nMRI pelvis (Figures \n2\n-\n3\n) were done in our hospital, which revealed an ill-defined heterogeneously enhancing\ncervical growth with heterogeneous endometrial collection showing restricted diffusion on MRI (Figure \n3\n)\nsuggestive of pyometra. The growth was extending and involved the lower half of the uterus superiorly, the\nupper half of the vagina inferiorly, the posterior wall of the urinary bladder anteriorly, and the mesorectal\nfascia posteriorly with loss of fat planes with the rectum. Bilateral parametrium involvement and loss of fat\nplanes with bilateral lower ureters were noted. Multiple intramural, subserosal, and submucosal fibroids\nwere also noted, with a few of them showing calcific degeneration. Multiple heterogeneously enhancing\nlymph nodes were noted in the bilateral external iliac region.\n1\n1\n1\n2\n3\n \nOpen Access Case Report\nPublished via DMIHER Datta Meghe Medical\nCollege\nHow to cite this article\nDhabalia R, Parihar P, Kashikar S V, et al. (July 20, 2024) A Rare Case of Pyometra in a 65-Year-Old Post-menopausal Woman. Cureus 16(7):\ne64973. \nDOI 10.7759/cureus.64973\n\nFIGURE\n 1: CECT abdomen and pelvis sagittal (A), coronal (B), and axial\n(C) sections showing heterogeneously enhancing cervical growth\n(arrow) involving the lower half of the uterus and the upper half of the\nvagina with resultant endometrial collection (star) and multiple fibroids\nwith calcific degeneration.\nCECT: Contrast-enhanced CT\nFIGURE\n 2: MRI abdomen and pelvis T2 (A), T2-FS (B), and T1-C+ sagittal\nsections showing heterogeneously hyperintense cervical growth (arrow)\ninvolving the lower half of the uterus and the upper half of the vagina\nwith heterogeneous enhancement (C) and resultant hyperintense\nendometrial collection showing fluid-fluid level (star) and multiple\nfibroids with calcific degeneration.\nFS: Fat saturated; C+: Contrast\nFIGURE\n 3: MRI abdomen and pelvis T2-FS (A), T1-C+ (B), and DWI axial\nsections showing heterogeneously hyperintense endometrial collection\n(star) and restricted diffusion in DWI (C) suggestive of pyometra. A\nsubmucosal fibroid (arrow) can also be seen adjacent to the\nendometrial collection.\nFS: Fat saturated; C+: Contrast; DWI: Diffusion-weighted imaging\nShe was started on empirical antibiotics, and her cervical biopsy was done that revealed histopathological\nfeatures (Figure \n4\n) suggestive of moderately differentiated squamous cell carcinoma. She was then referred\nto our cancer hospital, where she underwent six cycles of chemotherapy. Later, she came for a follow-up\n \nPublished via DMIHER Datta Meghe Medical\nCollege\n2024 Dhabalia et al. Cureus 16(7): e64973. DOI 10.7759/cureus.64973\n2\n of \n5\n\nMRI scan (Figure \n5\n), which showed no obvious evidence of any focal lesion or significant endometrial\ncollection suggestive of a complete response.\nFIGURE\n 4: H&E, 20x section showing moderately differentiated\ncribriform to papillary architecture with haphazard extension of glands\n(black circle) and stromal reaction in the form of edema and chronic\ninflammation.\nFIGURE\n 5: MRI abdomen and pelvis T2 (A), T2-FS (B), and T1-C+ (C)\nsagittal sections showing no evidence of any focal lesion or significant\nendometrial collection suggestive of complete resolution. Multiple\nuterine fibroids (arrows) with calcific degeneration can be seen.\nFS: Fat saturated; C+: Contrast\nDiscussion\nPyometra is a rare gynecological condition with an incidence of <0.01 % that should be included as a\ndifferential diagnosis in postmenopausal women who present with vaginal discharge and abdominal pain. It\nis most commonly seen in postmenopausal women and postpartum. It can also be seen in younger patients\nwith diabetes, cervical anomalies, cervicitis, large uterine fibroids, endocervical malignancy, recent vaginal\nsurgery, or injection drug use \n[7,8]\n. Pyometra develops due to cervical stenosis, which occurs due to thinning\nand atrophy of the cervix. However, endocervical malignancy should also be kept in mind. Cervical stenosis\ncan also develop in women with cervical malignancy due to the formation of fibrotic scar tissue after certain\nprocedures like brachytherapy, electrosurgical procedures, radiofrequency ablation, or cone biopsy \n[9]\n.\n \nPublished via DMIHER Datta Meghe Medical\nCollege\n2024 Dhabalia et al. Cureus 16(7): e64973. DOI 10.7759/cureus.64973\n3\n of \n5\n\nPyometra is often diagnosed incidentally \n[10]\n. It is caused by different microorganisms, the most common\nbeing \nStreptococcus, Bacteroides fragilis, and E. coli\n \n[11]\n, leading to the buildup of purulent fluid within the\nendometrial cavity. Patients present with clinical symptoms like abdominal pain, foul-smelling vaginal\ndischarge, itching in the perineal region, and fever with chills. It is assumed that pyometra is secondary to\nendocervical malignancy until proven otherwise \n[12]\n. The buildup of the purulent material increases the\nintrauterine pressure, which can lead to uterine rupture if left untreated. Therefore, prompt diagnosis and\ntreatment are required to prevent complications like peritonitis, hemorrhagic shock, fever, and bleeding due\nto spontaneous uterine rupture.\nPyometra is diagnosed using microbiological or radiological investigations. Transabdominal pelvic\nultrasound is the initial radiological investigation. Heterogeneous fluid collection with echogenic debris is\nseen on ultrasound. Higher imaging modalities like CT and MRI are used to rule out complications. On\ncontrast-enhanced CT (CECT), peripherally enhancing heterogeneous endometrial collection with an air-\nfluid level can be seen. Intraperitoneal free fluid or free air is seen in case of uterine rupture. On MRI, the\npurulent endometrial collection appears hypointense on the T1 weighted image (T1WI) and hyperintense on\nthe T2 weighted image (T2WI), showing restricted diffusion on diffusion-weighted imaging (DWI).\nTreatment of pyometra includes broad-spectrum antibiotic therapy to prevent peritonitis and sepsis,\nfollowed by cervical dilatation and drainage of the purulent collection. Surgical intervention is necessary in\npost-menopausal women due to high suspicion of endocervical malignancy \n[13]\n. In case of spontaneous\nrupture, the patient has to undergo peritoneal lavage and drainage, emergency laparotomy, or hysterectomy.\nConclusions\nWe have discussed a case of pyometra in a 65-year-old postmenopausal woman who presented with\nexcessive, foul-smelling white discharge from the vagina, itching over the perineal region, lower abdominal\npain, and postmenopausal bleeding. Ultrasound is the initial imaging modality, which revealed a\nheterogeneous cervical mass with resultant endometrial fluid collection and multiple uterine fibroids. CT\nand MRI revealed a heterogeneously enhancing ill-defined cervical mass involving the lower half of the\nuterus and the upper half of the vagina with resultant endometrial collection showing restricted diffusion on\nDWI suggestive of pyometra.\nPyometra is a rare cause of abdominal pain in post-menopausal women that is frequently overlooked.\nTherefore, it should always be included in the differential diagnosis. Malignancy should always be\nconsidered as the primary etiology until proven otherwise. Early diagnosis and treatment is necessary to\nprevent complications like uterine rupture and peritonitis.\nAdditional Information\nAuthor Contributions\nAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of the\nwork.\nConcept and design:\n  \nRishabh Dhabalia, Pratapsingh Parihar, Shivali V. Kashikar\nAcquisition, analysis, or interpretation of data:\n  \nRishabh Dhabalia, Pratapsingh Parihar, Shivali V.\nKashikar, Suhit Naseri, Shakti Sagar\nDrafting of the manuscript:\n  \nRishabh Dhabalia\nCritical review of the manuscript for important intellectual content:\n  \nRishabh Dhabalia, Pratapsingh\nParihar, Shivali V. Kashikar, Suhit Naseri, Shakti Sagar\nSupervision:\n  \nPratapsingh Parihar, Shivali V. Kashikar, Suhit Naseri, Shakti Sagar\nDisclosures\nHuman subjects:\n Consent was obtained or waived by all participants in this study. \nConflicts of interest:\n In\ncompliance with the ICMJE uniform disclosure form, all authors declare the following: \nPayment/services\ninfo:\n All authors have declared that no financial support was received from any organization for the\nsubmitted work. \nFinancial relationships:\n All authors have declared that they have no financial\nrelationships at present or within the previous three years with any organizations that might have an\ninterest in the submitted work. \nOther relationships:\n All authors have declared that there are no other\nrelationships or activities that could appear to have influenced the submitted work.\nReferences\n1\n. \nMori KM, Epstein HD, Roossin MC, Goldstein BH: \nA rare case of idiopathic pyometra in a premenopausal\n \nPublished via DMIHER Datta Meghe Medical\nCollege\n2024 Dhabalia et al. Cureus 16(7): e64973. 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