Spontaneous Perforation of Pyometra in a Postmenopausal Woman with Intrauterine Device Presenting with Septic Shock: A Case Report and Review of Published Cases.

A 69-year-old woman (19 years postmenopausal) presented with 24 hours of acute abdominal pain and fever (39°C), accompanied by vomiting. Before admission, she had received vaginal medication because of vaginal discharge; subsequently, fever occurred, and antibiotic treatment proved ineffective. The patient was referred to our hospital for further evaluation. Contrast-enhanced CT showed pneumoperitoneum, pelvic effusion, bilateral pneumonia, and a retained intrauterine device (IUD) ( Figure 1 ). Figure 1 Contrast-enhanced CT demonstrating gas within the myometrium and pelvic cavity. ( A ) The red arrow indicates gas collections in the pelvic cavity, the yellow arrows indicate the intrauterine device (IUD), and the red circle indicate the contour of the uterus. ( B ) The Orange arrow indicates gas within the myometrium, and the red circle indicate the contour of the uterus. Image A shows a contrast-enhanced CT scan of the pelvic region of a 69-year-old woman. A red arrow points to gas collections in the pelvic cavity. Yellow arrows indicate the intrauterine device and a red circle outlines the contour of the uterus. Image B displays another CT scan of the same region. An orange arrow points to gas within the myometrium and a red circle again outlines the contour of the uterus. The scans demonstrate pneumoperitoneum, pelvic effusion and a retained intrauterine device. Two CT scans showing gas in the myometrium and pelvic cavity of a 69-year-old woman. Contrast-enhanced CT demonstrating gas within the myometrium and pelvic cavity. ( A ) The red arrow indicates gas collections in the pelvic cavity, the yellow arrows indicate the intrauterine device (IUD), and the red circle indicate the contour of the uterus. ( B ) The Orange arrow indicates gas within the myometrium, and the red circle indicate the contour of the uterus. Laboratory tests demonstrated leukocytosis (WBC 22.18 x 10^9/L), elevated C-reactive protein (412.6 mg/L), coagulopathy (PT 18.5 s; INR 1.73), renal dysfunction (creatinine 116.7 µmol/L; urea 12.6 mmol/L), lactate level: 3.8 mmol/L (normal reference range: 0.5–2.2mmol/L) and hyperglycemia (glucose 8.23 mmol/L). Her medical history included hypertension and prior intracerebral hemorrhage with chronic cerebral infarction. On admission, she was in septic shock with tachycardia (142 beats/min) and tachypnea (36 breaths/min), blood pressure: 119/71 mmHg, shock index: (SI) 1.19; SpO2: 90% under oxygen therapy. Abdominal examination revealed diffuse tenderness with guarding and rebound. The initial working diagnosis included gastrointestinal perforation, diffuse peritonitis, septic shock, pneumonia, and acute kidney injury. The general surgery team performed an exploratory incision approximately 15 cm long via the right rectus abdominis muscle during the procedure. Emergency laparotomy revealed approximately 1000 mL of purulent intraperitoneal fluid. No gastrointestinal perforation was identified. A 3×4 cm necrotic area was visible on the posterior wall of the uterus, with a central perforation; a circular IUD is observed within the cavity ( Figure 2 ). Purulent coating was observed on the surfaces of both fallopian tubes and ovaries, with the IUD already removed. After intraoperative consultation with gynecology, given the difficulty of performing a hysterectomy through the exploration incision, laparoscopic total hysterectomy with bilateral salpingo-oophorectomy and pelvic drainage (last 13 days) was performed after suturing. Postoperative uterine section revealed cervical canal adhesions. Histopathology confirmed uterine perforation with acute suppurative inflammation, Microscopy showed disruption of the myometrial wall, extensive loose edema of the stroma, accompanied by diffuse infiltration of numerous lymphocytes and inflammatory cells, as well as fibrinoid necrosis, suggesting local tissue damage following perforation with an acute‑chronic inflammatory reaction, no evidence of malignancy ( Figure 3 ). Intraoperative pus culture yielded Gram-positive cocci, and blood culture showed no bacterial growth after 5 days. The patient was managed in the intensive care unit for sepsis and septic shock. Postoperatively, the patient received a 15-day course of meropenem. The incision healed primarily, with suture removal on postoperative day 15. However, the course was complicated by pneumonia, bilateral pleural effusion, and type I respiratory failure. Concurrent with declining infection markers, the patient was transferred to the respiratory intensive care unit. Bronchoscopy with bronchoalveolar lavage (BAL) yielded fluid that was analyzed by metagenomic next-generation sequencing (mNGS), which revealed high sequence counts of Candida albicans and herpes simplex virus. This prompted a 13-day course of combination therapy with fluconazole, cefoperazone-sulbactam, and moxifloxacin. She recovered and was discharged on postoperative day 28. At 2-, 6-, and 12-month follow-up, she remained well without complications ( Figure 4 ). Figure 2 Intraoperative view showing a uterine rupture in the posterior uterine wall with purulent discharge. Labeled structures: ( a ) the uterus, ( b ) the uterine rupture site, ( c ) the fallopian tube, and ( d ) the ovary. The intraoperative view shows a uterine rupture in the posterior uterine wall with purulent discharge. Labeled structures include the uterus (a), the uterine rupture site (b), the fallopian tube (c) and the ovary (d). The image captures the surgical exploration revealing the rupture and associated purulent discharge, highlighting the affected anatomical structures. The uterus is centrally positioned, with the rupture site visible as a necrotic area. The fallopian tubes and ovaries are positioned on either side of the uterus, showing signs of purulent coating. This view is part of a surgical procedure addressing the rupture and its complications. Uterine rupture with pus discharge, showing uterus, rupture site, fallopian tube and ovary. Figure 3 Uterine Perforation with Inflammatory Reaction (H&E Staining, ×200). A micrograph displays a pink and purple stained tissue field composed of densely distributed round to oval dark purple nuclei dispersed throughout. Numerous clear round to irregular vacuole-like spaces of varying sizes occupy much of the field, creating a foamy, perforated texture. Between these clear spaces, pale pink cytoplasmic areas form thin rims and small clusters. Several larger, more intensely pink regions form irregular patches without sharp borders, interspersed among the vacuolated areas. The background is uniformly pale with no scale bar, magnification text, or annotation labels. Micrograph: pink/purple tissue, clear vacuoles, dark nuclei on pale background. Figure 4 Summary of the patient’s clinical course and management. A medical timeline infographic: Emergency visit for vaginal discharge, acute abdominal pain, fever (39°C). Admission: CT shows pneumoperitoneum, pelvic effusion, bilateral pneumonia, retained IUD. Septic shock indicators: WBC 14.2, RR 36, Shock index 1.19, SpO2 90%. Surgery: IUD removed, total hysterectomy BSO, pelvic drainage. ICU Day 1–14: Meropenem therapy. Histopathology: Uterine perforation, acute inflammation. Pus culture: Gram-positive cocci. Blood culture: No growth (5 days). RICU Day 5–27: Pneumonia, pleural effusion, respiratory failure. mNGS: Candida albicans, Herpes simplex virus. Antibiotics changed to Fluconazole, Cefoperazone-sulbactam, Moxifloxacin. Day 28: Recovered. Follow-up (2, 6, 12 months): Complete healing, no complications. A medical timeline infographic of emergency IUD-related infection, surgery, ICU care and recovery follow-up. Intraoperative view showing a uterine rupture in the posterior uterine wall with purulent discharge. Labeled structures: ( a ) the uterus, ( b ) the uterine rupture site, ( c ) the fallopian tube, and ( d ) the ovary. Uterine Perforation with Inflammatory Reaction (H&E Staining, ×200). Summary of the patient’s clinical course and management. Pyometra is an uncommon but potentially life-threatening condition that typically presents with purulent vaginal discharge, postmenopausal bleeding, or lower abdominal pain; however, more than half of affected patients are asymptomatic until complications occur. 8 , 9 Gynecological examination and ultrasonography may contribute to the diagnosis of pyometra, especially in patients with an unruptured pyometra or a retained IUD. SPP is even rarer, with an estimated incidence of 0.01% - 0.05%. 4 , 5 It is generally thought to result from cervical obstruction, which promotes progressive distension, ischemia, and eventual necrosis of the uterine wall. 10 To better characterize this condition, we searched the Web of Science, PubMed and Medline databases from 1948 to the present using the terms “spontaneous perforation of pyometra”, “spontaneous uterine rupture”, “spontaneous uterine perforation,” “uterine perforation”, and “uterine rupture”. Only English-language articles were included, which may have introduced language bias. The search (covering 1948 to 2025) yielded 9446 records. Inclusion criteria were limited to cases of spontaneous perforation, including those associated with malignancy. Excluded were non-perforated cases of pyometra, postpartum or pregnancy-related uterine rupture, and cases of spontaneous perforation in other mammals. Cases with mixed etiologies and duplicate records were also excluded. By identifying the digital object identifier (DOI), patient information in the article, and verifying journal and author information, duplicates were removed. After screening, 9388 records were excluded, 58 articles reporting 65 previously reported cases were identified 2–59 ( Table 1 ). Including the present case, a total of 66 cases were analyzed. We summarized epidemiologic features, diagnostic pitfalls, management strategies, and outcomes based on detailed clinical descriptions. Because this review relies mainly on case reports and small case series, the findings are subject to certain limitations. Table 1 Summary Table of Previously Published Cases of Spontaneous Perforation of Pyometra Reference Authors Year Age Symptoms Imaging Initial Diagnosis Comorbidities Perforation Site Treatment Culture Results Outcome Hospitalization Cause of Death (If Applicable) [ 11 ] Hosking, S. W. 1985 77 LAP, N     Stroke, PD, Atherosclerosis, EC Fundus TAH+BSO (removal at autopsy) Escherichia coli, Bacteroides fragilis Died BSC MI [ 12 ] Parkinson, D. J. Alderman, B. 1985 78 AP, N, V X-ray     Fundus TAH+BSO   Survived     [ 13 ] Jones, V. A. Elkins, T. E. Wood, S. A. Buxton, B. H. 1986 41 AP, N   PGIT DUF Right side TAH Bacteroides fragilis Survived     [ 14 ] Bui, A. Wilkinson, S. 1989 73 Dia, AP, V X-ray AMHI?DP   Fundus TAH Strep.intermedius, Anaerobic strep, Fusobacterium Survived 38   [ 55 ] Kimura, H. Sodani, H. Takamura, H. et al 1994 72 AP, V, Con X-ray DP   Fundus TAH+BSO Escherichia coli Survived 74   [ 15 ] Sawabe, M. Takubo, K. Esaki, Y. et al 1995 86 AP, F X-ray, US PGIT   Fundus D Bacteroides fragilis, Peptostrept. Asaccharolyticus, Peptostrept. Anaerobius Escherichia coli Died 7 DIC [ 16 ] Ikematsu, Y. Kitajima, T. Kamohara, Y. et al 1996 80 AP, F X-ray, CT PGIT   Anterior TAH+BSO Escherichia coli Survived 13   [ 18 ] Inui, A. Nitta, A. Yamamoto, A. et al 1999 88 V, AN X-ray PGTI; DP   Fundus TAH+BSO Escherichia coli. Survived 68   [ 19 ] Tan, L. K. Busmanis, I. 2000 66 AP X-ray, CT SPP, DP   Fundus TAH+BSO Proteus mimbilis, Klebsiella species Died 47 MOF [ 56 ] Louis Yik-Si Chan Vivian S.Y.Yu L.C.Ho et al 2000 76 AP X-ray, CT DP   Fundus Hys+D Escherichia coli Survived 6   34 EP X-ray DP CC II after radiotherapy, PN Left side D Streptococcus, Bacteroides fragilis Survived 57   [ 17 ] Nakao, A. Mimura, H. Fujisawa, K. et al 2000 86 AP, F X-ray, CT SPP, DP Adenomyosis Fundus SVH Clostridium sphenoides Survived 11   [ 20 ] Iwase, F. Shimizu, H. Koike, H. et al 2001 69 AP, V US, CT AI, DP MA Fundus TAH Anaerobes Died 6 MOF 89 AP, V, S CT DP, SPP? CHF Fundus TAH+BSO Escherichia coli Died 35 ACS [ 21 ] Omori, H. Asahi, H. Inoue, Y. et al 2003 78 AP X-ray, CT AA   Fundus TAH         [ 22 ] Chan, K. S. Tan, C. K. Mak, C. W. et al 2006 73 AP, S, DC, CT P/PHO, SS DB Fundus TAH+BSO Klebsiella pneumoniae, Streptococcus viridans Survived 14   [ 23 ] Nuamah, N. M. Hamaloglu, E. Konan, A. 2006 79 V, AP, AD   PGIT, DP   Fundus TAH+BSO   Died 28 MOF [ 24 ] Yildizhan, B. Uyar, E. Sismanoglu, A. et al 2006 92 AP, V X-ray, CT PGIT   Fundus TAH+BSO Escherichia coli, Bacteroides fragilis Survived, SWH 18   [ 26 ] Tsai, M. S. Wu, M. H. 2006 40 F, AP X-ray, CT PA, PNP DB Fundus SH   Survived     [ 40 ] Shahid, N. Khan, H. Onon, T. S. 2006 80 VD US SCP CC Fundus Hys+D, then TAH+BSO         [ 27 ] Li, C. H. Chang, W. C. 2008 69 VD, AP, F, V, AN CT SS, PGIT IUD Anterior D, then TAH+BSO Bacteroides fragilis Survived 36   [ 28 ] Saha, P. K. Gupta, P. Mehra, R. et al 2008 60 AP X-ray, US PGIT   Fundus TAH+BSO Staphylococcus aureus Survived 28   [ 30 ] Vyas, S. Kumar, A. Prakash, M. et al 2009 60 VD, AP, V US, CT SPP CC IIIb   D Acinobacter Survived 7   [ 29 ] Izumi, J. Hirano, H. Yoshioka, H. et al 2010 83 AP US, CT P, DP     TAH+BSO Bacteroides distasonis, Porphyromonas asaccharolytica, Streptococcus oralis Survived 76   [ 31 ] Kim, J. Cho, D. H. Kim, Y. K. et al 2010 80 LAP X-ray, CT, MRI P, PS, OA?, MTU? Cholecystectomy Fundus TAH+BSO   Survived 9   [ 57 ] Bindiya Gupta Rachna Agarwal Gita Radhakrishnan 2011 55 AP X-ray IP   Anterior TAH+BSO   Survived 21   [ 32 ] Stunell, H. Hou, D. Finlayson, S. et al 2011 64 LAP, F CT PGIT/SPP? PRSL, Cervical polyp Left side TAH+BSO         [ 33 ] Sahoo, S. P. Dora, A. K. Harika, M. et al 2011 50 F, AP X-ray PHO, DP, SS   Fundus TAH+BSO   Survived, SWH     [ 34 ] Agarwal, R. Suneja, A. Sharma, A. et al 2011 60 F, C, AP, AD X-ray IP, DP CC Fundus D   Survived     [ 58 ] Chauhan, Meenakshi Barsaul Malhotra, Vani Malhotra, Naveen et al 2012 60 F, AP US, X-ray, CT PU   Posterior TAH+BSO   Died 3   [ 35 ] Mallah, F. Eftekhar, T. Naghavi-Behzad, M. 2013 78 F, V, AP   TH   Fundus TAH+BSO   Survived 20   61 F, N, AP   ROA, DP   Posterior TAH+BSO   Survived 30   [ 36 ] Abu-Zaid, A. Alomar, O. Nazer, A. et al 2013 63 F, N, V, AD X-ray; CT SPP, DP   Fundus TAH+BSO Streptococcus constellatus Survived 15   [ 37 ] Patil, V. Patil, L. S. Shiragur, S. et al 2013 74 AP, F, AD US, X-ray PHO   Fundus TAH+BSO   Survived 12   [ 38 ] Kutuk, M. S. Ozgun, M. T. Tas, M. et al 2013 71 AP, V, F, MS CT DP   Posterior TAH+BSO   Survived, SWH 21   75 AP, V CT MAI AF, LSH Right posterior TAH+BSO   Survived 13   68 AP CT PGIT RF, RA, Os Posterior TAH+BSO   Died 14 H [ 3 ] Yousefi, Z.Sharifi, N. Morshedy, M. 2014 70 AP, V, LA, VB US, CT DP CC Anterior TAH+BSO   Died 10 Hour SS/CS [ 39 ] Kitai, T. Okuno, K. Ugaki, H. et al 2014 66 AP, N CT PGIT/PU, DP   Fundus TAH+BSO Klebsiella pneumoniae, Bacteroides fragilis, Escherichia coli Died 36 H, MOF, CI [ 41 ] Singh, A. Mundhra, R. Agarwal, T. et al 2015 60 LAP, V CT PGIT, DP DB Posterior TAH+BSO Staphylococcus aureus Died 30 MOF [ 8 ] Yamada, T. Ando, N. Shibata, N. et al 2015 70 AP, V CT PGIT   Fundus TAH Bacteroides fragilis, Escherichia coli, Eubacterium Died 16 H [ 42 ] Islek Secen, E. Agis, H. Altunkaya, C. et al 2015 82 AP CT PGIT   Anterior TAH+BSO   Died 2 MOF [ 25 ] Chauhan, Ashutosh Sharma, Mala Mathur Banerjee, J. K. 2015 63 AP, V, F US, CT PGIT, DP DB   TAH+BSO   Survived 15   [ 2 ] Yin, W. B. Wei, Y. H. Liu, G. W. et al 2016 67 VD, LAP, F, N, V CT PGIT   Fundus TAH+BSO Staphylococcus epidermidis Survived, SWH 30   [ 10 ] Sharma, N. Singh, A. S. Bhaphiralyne, W. 2016 65 VD, F, LAP MRI SPP   Anterior Hys+D Gram positive cocci Survived 15   [ 44 ] Uno, K. Tano, S. Yoshihara, M. et al 2016 90 VD, AP, V, F US, CT PGIT, DP, PU HT, DB, AF Fundus TAH+BSO Escherichia coli, Peptostreptococcusasaccharolyticus Survived 13   [ 45 ] Kroon, H. M. Smolders, R. G. 2016 65 AP CT SPP CC IIa Fundus D, then RH   Survived 46   [ 46 ] Konishi, Y. Kagabu, S. Mori, K. et al 2016 64 AP, VD, LAP MRI CC IIb, P CC Fundus PL+D   Survived     [ 43 ] Desai, A. Y. Palande, B. Dhabolkar, S. et al 2017 60 AP X-ray PUP   Fundus TAH   Survived 5   70 AP X-ray DP   Fundus TAH   Survived 7   [ 47 ] Su, H. Y. Hung, Y. H. Li, H. M. et al 2017 73 AP CT SPP, DP   Fundus TAH+BSO   Survived 30   [ 7 ] Emergui Zrihen, Y. Obreros Zegarra, L. P.Garcia Hernandez, J. A. 2017 69 LAP US AA   Fundus, Posterior TAH+BSO Aerobic and anaerobic mixed flora with polymorphonuclears Survived 16   [ 48 ] Balas, S. Yilmaz, K. B. Yildirim, S. A. et al 2018 87 AP, F, V X-ray, US, SPP HT, DB Fundus TAH+BSO Escherichia coli Survived 28   [ 9 ] Huang, Y. Tian, Q. 2018 72 VD, AP US, CT H HT Posterior TAH+BSO Streptococcus pharyngitis Survived; SWH 30   [ 59 ] Kiyak Huseyin, Karacan Tolga et al 2020 80 AP, VD CT AP, SS   Fundus TAH+BSO Enterococcus faecalis Died 15 SS, MOF [ 49 ] Yazawa, H. Imaizumi, K. 2020 88 AP CT   SCC, UF Fundus TAH+BSO+resection of sigmoid colon Escherichia coli Died 189 GP, Pne 93 AP, VD CT P   Anterior D Escherichia coli Survived 35   [ 50 ] Matsumoto, R. Kuramoto, S. Muronoi, T. et al 2021 83 F, AP CT DP, SS HT Fundus TAH+BSO Proteus mirabilis Survived 32   [ 6 ] Li, X. L. Lin, J. 2022 72 Oli, CP, Dys CT P, SS   Fundus TAH+BSO   Survived 21   [ 4 ] Browne, I. L. 2022 68 AP, T, F X-ray, CT DP, PHO, P Ca, HP, DB, Ost Fundus Hys+D   Survived     [ 51 ] Pushpalatha, K. Singh, B. Kalra, R. et al 2022 60 AP, V   IP, DP   Anterior TAH+BSO   Survived     [ 52 ] Biller, J. Winegardner, B.S. Sleet, M. 2022 80 AP, V, Dia, F CT SCP OMC Posterior TAH+BSO Bacteroides fragilis, Escherichia coli Died 1 Abandon [ 5 ] Krishna, N. Aggarwal, K. Lal, P. et al 2024 52 LAP, F US, X-ray, MRI Pyo, UR   Right side TAH+BSO Escherichia coli Survived; SWH 36   [ 53 ] Mohd Hanapiah, F. Ismail, Z. K. A. Puteh, O. et al 2024 75 F, V, AP US, CT GMO, SCC BA, HT, HL Fundus TAH+BSO Escherichia coli Survived 52   *   2024 69 AP, N, F, V CT PGIT IUD Posterior TAH+BSO (Lap)   Survived 28   [ 54 ] Vadhadiya, R. Dwidmuthe, K. S. Bhalerao, A. et.al 2025 52 F, PN, N, V, Con US, CT AA, IP, DP BA Fundus, Anterior TAH+BSO   Survived     Abbreviations : AP, Abdominal pain; LAP, Lower abdominal pain; EP, epigastric pain; AN, anorexia; N, nausea; V, vomit; AD, abdominal distension; VB, vomit blood; F, Fever; S, Shock; Oli, oliguria; CP, chest pain; VD, vaginal discharge; PN, pain around the navel; Con, constipation; T, tachycardia; Dys, dyspnea; Dia, diarrhea; LA, Loss of appetite; MS, muscular soreness; C, chills; DC, disturbance of consciousness; S, Somnolence; US, ultrasound; AA, acute appendicitis; IP, intestinal perforation; AI, abdominal infection; DP, Diffuse Peritonitis; PUP, peptic ulcer perforation; PGIT, perforation of the gastrointestinal tract; PU, perforation of uteru; SPP, spontaneous pyometra perforation; P, Pyometra; PS, Pyosalpinx; ROA, rupture of ovarian abscess; OA, ovarian abscess; PHO, Perforation of hollow organs; GMO, Gastrointestinal malignancy with obstruction; MTU, malignant tumor of uterus; SCC, Sigmoid colon carcinoma; SCP, Sigmoid colon perforation; TH, tonic hernia; PA, perforation of abscess; HT, hypertension; MA, muscular atrophy; PRSL, Postoperative radiotherapy for sarcoma of left leg; HL, hyperlipemia; AF, atrial fibrillation; UF, uterine fibroids; DUF, Degeneration of uterine fibroids; CC, cervical carcinoma; PN, percutaneous nephrostomy; CHF, congestive heart failure; ARF, acute renal failure; RA, rheumatic arthritis; Os, Osteoporosis; SWH, secondary wound healing; LSH, Left-sided hemiplegia; TAH, total abdominal hysterectomy; SVH, Supravaginal hysterectomy; BSO, bilateral salpingo-oophorectomy; RH, radical hysterectomy; SH, subtotal hysterectomy; PRS, partial resection of sigmoid colon; Hys, hysterorrhaphy; D, Drainage; PL, peritoneal lavage; PNP, pneumoperitoneum; NM, not mentioned; AA, Acute Abdomen; MOF, multiple organ failure; SS, Septic Shock; MAI, Mesenteric artery ischemia; AMHI, acute mesenteric hemorrhage with infarction; Sep, Sepsis; CS, cardiogenic shock; H, hematosepsis; Pne, pneumonia; BA, bronchial asthma; Pyo, pyoperitoneum; UR, Uterine rupture; DB, diabetes; Ost, osteoarthritis; Ca, cerebrovascular accident; ACS, Acute coronary syndrome; MI, Myocardial infarction; CI, cerebral infarction; PD, Parkinson’s disease; REF, respiratory failure; BSC, Before the surgery concludes; IUD, Intrauterine device; EC, endometrial cancer; OMC, ovarian mucinous cystadenoma;*, the current case. Summary Table of Previously Published Cases of Spontaneous Perforation of Pyometra Abbreviations : AP, Abdominal pain; LAP, Lower abdominal pain; EP, epigastric pain; AN, anorexia; N, nausea; V, vomit; AD, abdominal distension; VB, vomit blood; F, Fever; S, Shock; Oli, oliguria; CP, chest pain; VD, vaginal discharge; PN, pain around the navel; Con, constipation; T, tachycardia; Dys, dyspnea; Dia, diarrhea; LA, Loss of appetite; MS, muscular soreness; C, chills; DC, disturbance of consciousness; S, Somnolence; US, ultrasound; AA, acute appendicitis; IP, intestinal perforation; AI, abdominal infection; DP, Diffuse Peritonitis; PUP, peptic ulcer perforation; PGIT, perforation of the gastrointestinal tract; PU, perforation of uteru; SPP, spontaneous pyometra perforation; P, Pyometra; PS, Pyosalpinx; ROA, rupture of ovarian abscess; OA, ovarian abscess; PHO, Perforation of hollow organs; GMO, Gastrointestinal malignancy with obstruction; MTU, malignant tumor of uterus; SCC, Sigmoid colon carcinoma; SCP, Sigmoid colon perforation; TH, tonic hernia; PA, perforation of abscess; HT, hypertension; MA, muscular atrophy; PRSL, Postoperative radiotherapy for sarcoma of left leg; HL, hyperlipemia; AF, atrial fibrillation; UF, uterine fibroids; DUF, Degeneration of uterine fibroids; CC, cervical carcinoma; PN, percutaneous nephrostomy; CHF, congestive heart failure; ARF, acute renal failure; RA, rheumatic arthritis; Os, Osteoporosis; SWH, secondary wound healing; LSH, Left-sided hemiplegia; TAH, total abdominal hysterectomy; SVH, Supravaginal hysterectomy; BSO, bilateral salpingo-oophorectomy; RH, radical hysterectomy; SH, subtotal hysterectomy; PRS, partial resection of sigmoid colon; Hys, hysterorrhaphy; D, Drainage; PL, peritoneal lavage; PNP, pneumoperitoneum; NM, not mentioned; AA, Acute Abdomen; MOF, multiple organ failure; SS, Septic Shock; MAI, Mesenteric artery ischemia; AMHI, acute mesenteric hemorrhage with infarction; Sep, Sepsis; CS, cardiogenic shock; H, hematosepsis; Pne, pneumonia; BA, bronchial asthma; Pyo, pyoperitoneum; UR, Uterine rupture; DB, diabetes; Ost, osteoarthritis; Ca, cerebrovascular accident; ACS, Acute coronary syndrome; MI, Myocardial infarction; CI, cerebral infarction; PD, Parkinson’s disease; REF, respiratory failure; BSC, Before the surgery concludes; IUD, Intrauterine device; EC, endometrial cancer; OMC, ovarian mucinous cystadenoma;*, the current case. Based on the 66 currently published cases, patient age ranged from 34 to 93 years (median 71 years). 89.4% of patients were 60 years or older, underscoring a predominance among postmenopausal women. This distribution likely reflects age-related changes including reduced estrogen levels, cervical stenosis, and impaired immune function, which predispose to pyometra formation and subsequent perforation. 15 , 43 Based on the 66 cases currently published, 31 patients (47.0%) had documented comorbidities, commonly reported associated conditions including hypertension, diabetes mellitus, renal dysfunction, and prior cerebrovascular events, as well as gynecologic conditions such as uterine fibroids, adenomyosis, cervical malignancy, and cervical polyps. Seventeen patients had gynecologic comorbidities, including cervical cancer (n = 7), uterine fibroids (n = 3), retained IUD (n = 2)- the IUD must be removed from postmenopausal women, adenomyosis (n = 1), cervical polyps (n = 1), endometrial cancer (n = 1), and ovarian mucinous cystadenoma (n = 1). Among patients younger than 50 years, two cases involved structural cervical abnormalities 13 or prior pelvic radiotherapy, 18 suggesting that anatomic distortion or iatrogenic injury may predispose to SPP. The typical manifestations of SPP include abdominal pain, fever, and vaginal discharge; however, approximately 50% of patients do not exhibit these classic symptoms. 8 , 9 In our review, abdominal pain was the most common symptom, reported in 60 of 66 patients (90.9%), including 9 cases with lower abdominal pain and 2 cases with upper abdominal pain. Other common manifestations included vomiting (39.4%) and fever (39.4%). Classic gynecologic symptoms such as purulent vaginal discharge were relatively uncommon (13.6%), whereas gastrointestinal-like symptoms (eg, nausea or abdominal distension) were reported in approximately 21.2% of cases. Imaging plays a central role in evaluating SPP. Among the 66 cases, imaging studies were explicitly described in 60 cases, 41 patients underwent CT, 26 had abdominal radiography, 17 underwent ultrasonography, and 4 were evaluated with magnetic resonance imaging (MRI). Based on the published cases, CT was the most informative modality and demonstrated several characteristic features. Among CT-evaluated cases, pelvic effusion was observed in 27 patients, uterine enlargement with intrauterine fluid in 21 patients, and pneumoperitoneum in 20 patients. These findings frequently mimic gastrointestinal perforation, contributing to the high rate of initial misdiagnosis. Importantly, uterine wall defects were identified on CT (including contrast-enhanced studies) in 12 patients and were confirmed intraoperatively, indicating that CT can directly demonstrate uterine perforation when image quality is adequate. Ultrasound was performed in 17 cases. Among these, possible uterine perforation was suggested in 2 cases, uterine enlargement in 2 cases, and uterine wall necrosis in 1 case; notably, all 17 cases showed pelvic or abdominal fluid. These observations suggest that ultrasound may have potential diagnostic utility in SPP, particularly when characteristic intrauterine and extracavitary findings are present. MRI was performed in only four cases 5 , 10 , 31 , 46 but identified the site of perforation in three. Given its superior soft-tissue contrast, MRI may provide additional diagnostic value in complex or equivocal cases, although its use is limited in emergency settings. 31 SPP is difficult to diagnose preoperatively because its presentation is nonspecific and overlaps with gastrointestinal emergencies. Among cases with adequate diagnostic descriptions, only 15.9% (10/63) were correctly diagnosed preoperatively, whereas 84.1% (53/63) were initially misdiagnosed. Among fatal cases, the misdiagnosis rate reached 93.8%, highlighting the consequences of delayed recognition. Common erroneous diagnoses included gastrointestinal perforation and diffuse peritonitis. Of note, given the wide time span of the included cases, the variable quality of imaging studies, and the evolving diagnostic criteria over time, the pooled rate of misdiagnosis should be interpreted with caution. Several factors contribute to diagnostic delay. First, gynecologic symptoms such as vaginal discharge or bleeding are often absent; more than half of patients are asymptomatic before perforation. 8 , 9 Second, pneumoperitoneum - often interpreted as a hallmark of gastrointestinal perforation - was present in nearly one-third of CT-evaluated cases, reinforcing diagnostic misdirection. 60 Third, many patients are elderly with multiple comorbidities or atypical symptoms such as nausea, vomiting, or abdominal distension, making early suspicion of a gynecologic cause less likely. Clinicians should maintain suspicion for SPP in postmenopausal women presenting with acute abdomen and pneumoperitoneum, and particular attention should be given to patients presenting with a history of vaginal discharge, imaging findings showing an enlarged uterine volume or intrauterine fluid/debris, the presence of gas within the uterine cavity or myometrium, retained IUD, and the absence of any obvious gastrointestinal lesions. Microbiological data were available for 36 of the 66 reported cases, yielding 49 isolated organisms from the purulent material ( Table 2 ). These pathogens primarily belonged to three groups: Gram-negative bacilli, anaerobes , and Gram-positive cocci . Enterobacteriaceae were most common (22/49, 44.9%), with Escherichia coli accounting for 77.3% (17/22). Anaerobes accounted for 34.7% (17/49), most frequently Bacteroides fragilis (9/17, 52.9%). Gram-positive cocci comprised 20.4% (10/49). Table 2 Bacterial Profile and Case Fatality Rate in Pus Culture Bacterial Name Counting Died num Classification Escherichia coli 17 7/16 (43.75%) Enterobacteriaceae (Gram-negative bacilli) Klebsiella pneumoniae 3 1/16 (6.25%) Proteus mirabili 2 1/16 (6.25%) Bacteroides fragilis 9 6/16 (37.5%) Anaerobic bacteria Bacteroides distasonis 1 0 Clostridium sphenoides 1 0 Porphyromonas asaccharolytica 1 0 Aerobic and anaerobic mixed flora with polymorphonuclears 1 0 Anaerobic strep 1 0 Peptostrept. Asaccharolyticus 1 1/16 (6.25%) Prevotella intermedia 1 0 Anaerobes 1 1/16 (6.25%) Staphylococcus aureus 2 1/16 (6.25%) Staphylococcus genus Gram-positive cocci Staphylococcus epidermidis 1 0 Streptococcus oralis 1 0 Streptococcus Streptococcus 1 0 Streptococcus constellatus 1 0 Strep.intermedius 1 0 Streptococcus pharyngitis 1 0 Enterococcus faecalis 1 1/16 (6.25%) Enterococcus genus Gram positive cocci 1 0 Gram-positive cocci Toal 49 Bacterial Profile and Case Fatality Rate in Pus Culture Among the 16 patients who died and had microbiological results available, 11 underwent pus culture, yielding 19 isolated organisms. Of these, 89.5% (17/19) had infection due to Enterobacteriaceae and/or anaerobic bacteria, and three involved polymicrobial infection. These findings suggest that mixed infections and Gram-negative or anaerobic pathogens may be associated with progression to sepsis and multiple organ failure. However, this conclusion still requires more evidence to support it. Overall, the microbiological profile supports early administration of broad-spectrum antibiotics targeting Enterobacteriaceae and anaerobes in suspected cases of SPP, followed by adjustment based on susceptibility testing. Among the 63 cases with perforation described, uterine fundal perforation occurred in 42 patients (66.7%), while anterior or posterior wall perforation occurred in 18 (28.6%). The predominance of fundal rupture may relate to the relatively thin myometrium at the fundus and the cumulative effect of intracavitary pressure. Surgery remains the cornerstone of management. In our review, 56 patients (84.9%) underwent total hysterectomy, fifteen of these patients died (26.8%). Several reports illustrate limitations of conservative management: two patients treated initially with peritoneal drainage alone later required hysterectomy for uncontrolled sepsis and both recovered. 6 , 18 Another patient underwent uterine repair with drainage but required subsequent hysterectomy due to persistent infection and recovered. 42 Alternative approaches may be considered in patients who are poor candidates for hysterectomy because of advanced age, frailty, or severe comorbidities. Six patients (9.1%) underwent peritoneal lavage with drainage alone, with one death reported (16.7% mortality). Three patients underwent uterine repair with drainage, and one underwent subtotal hysterectomy. Although these limited interventions may be necessary in selected patients, mortality remained high. Hysterectomy with removal of the ruptured pyometra appears important for achieving a favorable outcome. 61 Thus, total hysterectomy with bilateral salpingo-oophorectomy and drainage was the most frequently reported definitive treatment. However, its superiority over conservative treatment options cannot be concluded from case reports. Treatment strategies should be individualized based on the patient’s hemodynamic stability, intraoperative findings, and surgical candidacy. Of the 66 patients identified in this review, outcome data were available for 63. Forty-seven patients (74.6%) survived and 16 (25.4%) died, a mortality rate comparable to the 25.0% (11/44) reported by Ikeda et al 61 Secondary wound healing was observed in 7 survivors (14.9%, 7/47). Hospitalization data were documented for 54 patients (85.7%); the median length of stay was 20.5 days (IQR 12.2–34.2; range 0.4–189 days). One patient died intraoperatively of myocardial infarction before the procedure could be completed. Among the 15 postoperative deaths, four occurred within 72 hours of surgery, largely due to septic shock and cardiogenic complications; in one of these cases the family elected to withdraw active treatment on postoperative day 1. Overall, 11 of 15 postoperative deaths (73.3%) occurred within the first 30 days. Multiple organ failure was the most common cause of death (7/16, 43.8%), followed by hematosepsis (4/16, 25.0%) and septic shock (1/16, 6.3%). Four patients had more than one documented cause of death ( Table 3 ). The estimated 7-, 14-, and 30 days survival rates were 86.9%, 84.6%, and 72.4%, respectively. Table 3 Causes of Death (n = 16) Cause of death n % Time to Death Multiple organ failure 7 43.8 2–189 days Hematosepsis 4 25 10 h–36 days Septic shock 1 6.3 15 days Cardiogenic shock 1 6.3 10 h Myocardial infarction 1 6.3 Intraoperative Disseminated intravascular coagulation 1 6.3 7 days Acute coronary syndrome 1 6.3 35 days Cerebral infarction 1 6.3 36 days General peritonitis / pneumonia 1 6.3 189 days Treatment withdrawal 1 6.3 1 day Unknown 1 6.3 3 days Causes of Death (n = 16)

Pyometra (uterine empyema) refers to accumulation of purulent material in the uterine cavity, most commonly due to cervical canal obstruction; however, its etiology is multifactorial, including malignancy, radiotherapy, infection, atrophic cervicitis, prior instrumentation, prolapse procedures, and foreign bodies, may also contribute to its development. 1 Although the overall incidence is low, it increases significantly in postmenopausal women because of cervical stenosis and an atrophic endometrium. 2 , 3 Spontaneous perforation of pyometra (SPP) is exceedingly uncommon 4 , 5 but may lead to diffuse peritonitis and septic shock, with a reported mortality of 25%-40%. 6 , 7 Here, we describe a rare case of SPP complicated by septic shock that was initially misdiagnosed as gastrointestinal perforation, followed by a literature review of 66 reported cases (including the present case) reported cases to summarize the epidemiology, diagnostic challenges, management strategies, and outcomes.

SPP is a rare but life-threatening condition that often mimics gastrointestinal emergencies, leading to frequent misdiagnosis, particularly in postmenopausal women. A retained IUD in postmenopausal women may be associated with an increased risk of SPP. Our patient presented with acute abdominal pain, fever, and vomiting. Despite the presence of a retained IUD, the preoperative diagnosis favored acute gastrointestinal perforation, and SPP was not considered. The failure to suspect SPP may be explained by its low incidence and insufficiently detailed history taking. CT may provide important diagnostic clues, such as pelvic fluid in the cul-de-sac, intrauterine fluid with or without gas, periuterine free air, and a focal uterine wall defect, especially without a clear gastrointestinal source—are key to timely diagnosis. 62 In this case, preoperative CT showed a retained IUD, pelvic fluid, and pneumoperitoneum without clear evidence of a uterine wall defect, which may have led to the misdiagnosis. Early source control surgery and broad-spectrum antibiotics are commonly required. Our patient was treated with emergency surgery and postoperative broad-spectrum antibiotics. She made a full recovery and was discharged. In conclusion, for postmenopausal women presenting with acute abdominal pain and pneumoperitoneum without an identifiable gastrointestinal source, SPP should be considered. Early recognition, prompt source control, and optimized supportive care are key to reducing fatal outcomes. However, the available evidence is limited, as this review is based almost entirely on case reports and small case series with heterogeneous data quality and diagnostic criteria. Therefore, the findings should be interpreted with caution, and treatment decisions must be individualized based on the patient’s clinical status. Heightened awareness and early source control are essential to reduce mortality.