First documented case of cervical stenosis resulting in pyometra and fallopian tube torsion

This case describes a rare association between cervical stenosis, pyometra, and FTT, marking it as the first documented instance in medical literature. The unique interplay of these conditions emphasizes the critical need for awareness and vigilance among healthcare providers, particularly in postmenopausal women with a history of recurrent genitourinary infections. Prompt recognition and intervention are essential to prevent serious complications, including necrosis of the affected structures. This case reinforces the importance of comprehensive evaluation and timely surgical management in patients presenting with nonspecific abdominal symptoms, highlighting the need for enhanced clinical awareness regarding such atypical but significant gynecological complications. This case illustrates a rare association between cervical stenosis, pyometra, and fallopian tube torsion in a postmenopausal patient. The report highlights that severe cervical obstruction may contribute to unusual intrauterine infectious complications and, in rare circumstances, adnexal torsion. Because the clinical presentation may be nonspecific, such conditions can be difficult to diagnose preoperatively. This case therefore adds to the limited literature on this uncommon combination and may help clinicians consider fallopian tube torsion as a potential differential diagnosis in similar clinical scenarios.

Cervical stenosis (CS) is characterized by narrowing or obstruction of the cervical canal that limits access to the uterine cavity and may involve the external cervical os, internal cervical os, or the cervical canal itself [ 1 ]. Cervical canal stenosis is defined as narrowing that prevents passage of a 2.5-mm Hegar dilator [ 7 ]. Conversely, external cervical os (ECO) stenosis refers to an ECO diameter that measures less than 4.5 mm [ 8 ]. ECO stenosis is more frequently seen in premenopausal women than in those who are postmenopausal. In contrast, ICO stenosis is more common in menopausal women [ 9 ]. Cervical stenosis can be classified into four categories based on the specific structures affected: ECO stenosis, cervical canal and ICO stenosis, ICO stenosis alone, and a combination of both ECO and ICO stenosis [ 9 ]. The condition may be congenital or acquired. Acquired causes include cervical procedures such as loop excision, conization, or endometrial ablation, as well as cervical trauma, infection, radiation exposure, and gynecologic malignancies [ 3 , 7 , 10 – 12 ]. In postmenopausal women, hypoestrogenic atrophic changes can progressively narrow the cervical canal, predisposing to intrauterine fluid accumulation such as hematometra, hydrometra, or pyometra [ 2 , 13 ]. For our patient, notable risk factors included a history of recurrent genitourinary infections and postmenopausal conditions. Patients with cervical stenosis are often asymptomatic and the condition is frequently discovered incidentally during evaluation of the uterine cavity [ 1 , 12 ]. However, severe obstruction may lead to complications related to retention of intrauterine contents, including hematometra, hydrometra, or pyometra [ 2 ]. In women of reproductive age, cervical stenosis may also contribute to infertility or menstrual outflow obstruction [ 8 , 14 ]. Management is generally recommended when symptomatic obstruction or complications occur, and treatment may include medical cervical ripening agents or surgical approaches such as cervical dilation or hysteroscopic intervention [ 1 , 15 ]. Our patient exhibited an uncommon sequence of clinical symptoms, specifically associated with pyometra. Pyometra is defined as the accumulation of purulent material within the uterine cavity and typically occurs when endometrial infection is combined with impaired cervical drainage [ 4 ]. Although uncommon, pyometra is clinically significant because it may lead to severe complications, including uterine perforation or sepsis [ 4 , 5 , 16 ]. In postmenopausal women, pyometra also warrants careful evaluation due to its potential association with underlying gynecologic malignancy [ 4 , 5 ]. Fallopian tube torsion (FTT) is a rare gynecologic emergency characterized by twisting of the fallopian tube along its vascular axis [ 17 ]. It most commonly occurs in women of reproductive age but has also been reported in pediatric and postmenopausal populations [ 17 , 18 ]. The exact cause of FTT remains unclear, but several risk factors have been identified and can be broadly classified into intrinsic and extrinsic categories [ 19 ]. The exact etiology remains unclear; however, several intrinsic and extrinsic risk factors have been described. Intrinsic factors include hydrosalpinx, hematosalpinx, tumors, endometriosis, or abnormal tubal mobility, while extrinsic factors may involve adjacent pelvic pathology, uterine enlargement, adhesions, or pelvic congestion [ 17 , 19 ]. Clinical diagnosis of FTT is challenging because patients typically present with nonspecific symptoms such as unilateral lower abdominal pain, nausea, and vomiting [ 20 , 21 ]. Imaging modalities including ultrasound, computed tomography, and magnetic resonance imaging may assist in evaluation but generally have limited sensitivity for definitive diagnosis [ 17 , 22 ]. Currently, laparoscopy is considered the gold standard for diagnosing FTT [ 22 ]. In the present case, cervical stenosis resulted in pyometra due to impaired cervical drainage. The resulting uterine enlargement and inflammatory environment may have contributed to the development of fallopian tube torsion, representing a rare sequence of pathological events. To our knowledge, an association between cervical stenosis–related pyometra and isolated fallopian tube torsion has not been previously documented in the literature. Management of FTT depends largely on intraoperative findings. When the fallopian tube remains viable after detorsion, conservative management may be considered. However, when vascular compromise or necrosis is present, salpingectomy is required [ 23 , 24 ]. In our patient, necrosis of the affected fallopian tube was observed during surgery, necessitating salpingectomy. In postmenopausal women presenting with pyometra, exclusion of underlying malignancy is an important component of management. Histopathological evaluation of endometrial tissue in this case demonstrated inflammatory changes without evidence of malignancy. Cervical cytologic evaluation was planned during follow-up after resolution of infection and improved cervical accessibility. Several clinical and contextual factors influenced the management strategy in this case. The patient presented with acute abdominal pain, leukocytosis, and imaging findings suggestive of adnexal torsion, necessitating urgent surgical intervention. Severe cervical stenosis significantly limited immediate cervical access for cytologic or biopsy evaluation, while hysteroscopy was unavailable at our institution. Therefore, surgical exploration, evacuation of the pyometra, and removal of the necrotic fallopian tube were prioritized to control infection and prevent septic complications. At the same time, endometrial biopsy was performed intraoperatively to exclude underlying malignancy, and cervical cytologic evaluation was planned during follow-up once inflammation resolved and cervical accessibility improved. These decisions were guided by the need to balance diagnostic evaluation with patient safety in the context of acute clinical urgency and limited procedural access.

Cervical stenosis (CS) is a condition marked by the narrowing of the cervical canal, which can lead to various complications, including pyometra and fallopian tube torsion [ 1 , 2 ]. While CS can often be asymptomatic or present with nonspecific signs, its clinical significance increases when it leads to infection or obstruction. Pyometra occurs when the uterine cavity accumulates pus due to an endometrial infection and cervical blockage, resulting in significant abdominal pain and other systemic symptoms [ 1 , 3 ]. The risk of FTT, although rare, can increase in the context of CS, particularly in postmenopausal women [ 1 , 3 – 5 ]. This case report details the first presentation involving a middle-aged Ethiopian woman with a history of recurrent genitourinary infections, who developed a rare complication of pyometra secondary to cervical stenosis, resulting in a torsion of the fallopian tube. By discussing this case, we aim to highlight the importance of awareness regarding the interplay between cervical stenosis, pyometra, and FTT. Early diagnosis and timely intervention are vital for preventing grave outcomes, including necrosis of the affected structures. The exact incidence and morbidity associated with fallopian tube torsion secondary to cervical stenosis remain unknown and require further investigation, but Premature labour is far more likely, and the risk of maternal morbidity and mortality higher, if infection of the abdominal cavity is allowed to occur [ 6 ]. This report contributes to the limited documentation of such associations in medical literature, emphasizing the need for meticulous evaluation in patients presenting with similar symptoms. A 60-year-old Ethiopian woman, para 5 and post-menopausal for 16 years, arrived at our hospital with a sudden onset of intermittent lower abdominal pain lasting 5 days, predominantly on the right side. Along with this, she reported nausea and five episodes of vomiting but denied fever or urinary symptoms. She had also noticed a small amount of intermittent foul-smelling whitish vaginal discharge and mild, dull lower abdominal pain for the previous month. Despite these symptoms, she had not sought any medical care. Her medical history included multiple treatments for vaginal discharge syndrome, with no history of vaginal bleeding or chronic illnesses. She denied exposure to medications such as diethylstilbestrol (DES) and had no prior surgeries or obstetric history. During physical examination, she appeared in distress due to pain. Although her blood pressure, respiratory rate, and temperature were normal, she was tachycardic at 119 beats per minute. Abdominal examination revealed a mass corresponding to a 14-week-size uterus, with tenderness noted, especially in the right lower quadrant. Speculum examination revealed an indistinct cervix, positioned flush with the posterior vaginal wall and covered by a small vaginal hood. Other physical examinations were unremarkable. To further investigate, an abdominopelvic ultrasound was performed, revealing a heterogeneous intrauterine fluid collection measuring 9.9 × 8.4 cm, along with an enlarged mass on the right side of the uterus (Fig.  1 ). Laboratory tests showed leukocytosis at 22,000 per microliter, predominantly neutrophils (91%), while other cell lines remained normal. Biochemical analyses including C- reactive protein and tumor marker tests were also within normal limits. Fig. 1 Shows preoperational abdominopelvic ultrasound with endometrial fluid Shows preoperational abdominopelvic ultrasound with endometrial fluid Given the likely diagnosis of adnexal mass torsion and an endometrial fluid collection, probably due to cervical stenosis (CS), the patient underwent a laparotomy. Intraoperative findings included a right fallopian tube demonstrating a 1080-degree counter-clockwise torsion and appeared edematous with a necrotic area (Fig.  2 ). The ipsilateral ovary and the contralateral reproductive structures were normal. The uterus was enlarged, corresponding to a 14-week-size uterus, and had a soft consistency, with no adhesion observed between the bowel loops and the right adnexal area. The right fallopian tube was untwisted, and a right salpingectomy was performed. Fig. 2 Right fallopian tube showing 1080-degree counterclockwise torsion(arrow) Right fallopian tube showing 1080-degree counterclockwise torsion(arrow) To manipulate the uterus, a sponge stick was placed in the vagina due to the absence of a visible cervix for a single-tooth tenaculum. A second operator placed two tenacula at the vaginal apex, revealing a pinpoint cervical os. Following cervical dilation, the pyometra was evacuated and the uterine cavity was thoroughly irrigated, an endometrial biopsy was obtained to rule out malignancy. Approximately 50 mL of frank pus was evacuated (Fig.  3 ), which was subsequently sent for culture and sensitivity. The vaginal epithelium was sharply dissected from the cervix, as hysteroscopy was unavailable; an ultrasound later indicated a normal endometrial cavity (Fig.  4 ). Fig. 3 Evacuated pus from the uterus Evacuated pus from the uterus Fig. 4 Uterus after evacuation Uterus after evacuation Histopathological examination of the endometrial tissue showed mixed lymphoplasmacytic and neutrophilic infiltration, while normal endometrial glands and stroma were noted, with no malignant cells identified (Figs.  5 and 6 ). The right fallopian tube specimen revealed inflammatory infiltrate, congested blood vessels, and extravasated blood in the stroma (Figs.  7 and 8 ). Cultures from the uterine pus showed no growth. Fig. 5 Section of endometrium: Mixed lymphoplasmacytic and neutrophilic infiltration Section of endometrium: Mixed lymphoplasmacytic and neutrophilic infiltration Fig. 6 Normal Endometrial gland (blue arrow) and Endometrial stroma (white arrow) Normal Endometrial gland (blue arrow) and Endometrial stroma (white arrow) Fig. 7 Fallopian tube section shows Remnant preserved stroma (double arrow) and Inflammatory cell infiltrates Fallopian tube section shows Remnant preserved stroma (double arrow) and Inflammatory cell infiltrates Fig. 8 Fallopian tube section shows congested blood vessels (double arrow) and Extravasated blood in the stroma (single arrow) Fallopian tube section shows congested blood vessels (double arrow) and Extravasated blood in the stroma (single arrow) Evaluating for cervical malignancy is essential in postmenopausal women with pyometra. In this patient, a Pap smear and cervical biopsy were not done intraoperatively because severe cervical stenosis made the cervix inaccessible, and no suspicious lesions were visible. The priority was to drain and evacuate the pyometra to prevent septic complications. An endometrial biopsy was performed, showing no malignancy. Pap smear and cervical cytology were planned for outpatient follow-up after inflammation and stenosis resolved, as immediate sampling would have low diagnostic yield and increased risk. Post-surgery, the patient was treated with broad-spectrum antibiotics and supportive care. She responded well without complications and was discharged on the seventh postoperative day. At a follow-up appointment two weeks later, she reported no fever, pain, or vaginal discharge, and a follow-up ultrasound showed normal results. A year after the treatment, she remained symptom-free.