Spontaneous Perforation of Pyometra Presenting as Generalized Peritonitis

Background: Spontaneous perforation of pyometra caused by nonmalignant conditions is rare. Case: A 93-year-old women presented with generalized peritonitis without a fever. Trans-abdominal ultrasound revealed a complex pelvic mass of 7 × 5.5 cm with echogenic fluid in her pelvis and abdomen. With a provisional clinical diagnosis of a ruptured tubo-ovarian abscess, an emergency laparotomy was perfomed, revealing a 10-week-size uterus with pyometra and a perforation of 0.5 cm on the anterior wall of her uterus together with 3 L of pus. Drainage of the pyoperitoneum along with a total abdominal hysterectomy and a bilateral salpingo-oopherectomy was performed, while the patient was on broad-spectrum antibiotics. She was given postoperative care in the respiratory intensive care unit because she required positive pressure ventilation. Her blood pressure was maintained with dobutamine and noradrenaline. A culture of the pus culture revealed an enterococcus infection. Results: The patient developed refractory metabolic acidosis and atrial flutter and expired 96 hours after her laparotomy. Conclusions: This case illustrates that pyometra can be asymptomatic until a catastrophic condition, such as perforation, occurs and, hence, a periodic health checkup in elderly women should also include a gynecological examination that includes ultrasound testing when indicated by any signs or symptoms. (J GYNECOL SURG 27:103)