Spontaneous perforation of pyometra due to acute necrotising endometritis

Abstract

A 64-year-old woman presented with a 1-day history of severe lower abdominal pain and pyrexia. Her medical history included a sarcoma of her left thigh treated with neo-adjuvant radiotherapy and subsequent surgical resection 2 years earlier. Wound necrosis requiring left groin reconstruction with a right rectus abdominis myocutaneous fl ap complicated her postoperative course. A massively distended air and fl uid-fi lled endometrial cavity, with marked thickening and enhancement of the myometrium was shown at CT. In the region of the left uterine fundus, there was a transmural defect containing multiple locules of air, suggesting a localised uterine perforation (Figure 1). Free intraperitoneal air and fl uid was present, with further locules of air and interloop fl uid identifi ed in the region of the duodenojejunal fl exure. An area of polypoid soft tissue was identifi ed in the lower uterine segment on the right, projecting into the uterine cavity (Figure 2). Pyometra with associated uterine perforation was suspected, and, given the history of prior sarcoma, the possibility of an underlying necrotic, perforated uterine tumour was considered. Th e diff erential diagnosis also included a secondary, localised small bowel perforation in the region of the duodenojejunal fl exure and interloop abscess. At laparotomy, there were 2 litres of frank pus in the peritoneal cavity. Th e uterus was grossly distended and a left myometrial perforation oozed purulent discharge. Secondary peritonitis involving the small and large bowel with multiple pockets of intramesenteric pus and locules of gas was also present, although there was no evidence of overt bowel perforation. In addition, signifi cant radiotherapy eff ect was present in the pelvic tissues. A total abdominal hysterectomy and bilateral salpingooophorectomy along with extensive peritoneal lavage was performed. Histological examination of the resected specimen showed marked myometrial thickening associated with dilatation of the endometrial cavity. Th e endometrium was ulcerated and covered with a haemorrhagic, grey – green exudate. Th e fi nal histological diagnosis was acute suppurative necrotising endometritis with abscess formation, full thickness necrosis of the uterine wall and serositis. Th ere was no evidence of malignancy. A 1.8 1.0 0.6 cm polypoid sub-mucosal fi broid was present in the lower uterine segment on the right, corresponding with the CT fi ndings. Its position, together with the adjacent radiotherapy eff ect, seemed to contribute to impaired drainage of the uterine cavity and subsequent development of pyometra in this patient.