Jpn. J. Infect. Dis.

, 61, 477-478, 2008

Short Communication

Spontaneous Perforated Pyometra with an Intrauterine Device

in Menopause: a Case Report
Chao-Hsu Li and Wen-Chun Chang1*
Department of Surgery, Buddhist Tzu-Chi General Hospital and 1Department of Obstetrics and Gynecology,
National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
(Received May 12, 2008. Accepted July 29, 2008)
SUMMARY: Spontaneous perforation of the uterus is rare and only several cases have been reported in the
English medical literature. Most of the patients had gynecological malignancy and almost all were associated
with cervical occlusion. We report a case of diffuse peritonitis resulting from spontaneously perforated pyometra
with an intrauterine device (IUD) inserted for more than two decades. This case differs from others in that the
cervical canal was not occluded. In the absence of other possible causes of uterine perforation, the etiology in
this case is mostly likely hemorrhagic necrosis related to the long-term IUD.
tion of creatinine (4.2 mg/dL). Parenteral empiric antibiotics
(imipenem, fluconazole, and metronidazole) were given for
profound septic shock. The fever subsided on postoperative
day 5 (POD5). The renal function returned to the normal range
on POD6 and hemodialysis was discontinued. The liver function test returned to the normal range on POD18. From POD6,
there was no more drainage from the rubber tubes. However,
fever and leukocytosis occurred with 115 mL drainage again
after imipenem was dispensed on POD9. Therefore, imipenem
was continued and the fever was controlled. An episode of
fever occurred again on POD18 in spite of the antibiotics.
The leukocyte count elevated from 8,210 to 13,630/mm3 and
C-reactive protein elevated from 2.87 to 10.27 mg/dL. Seven
blood cultures were collected and oxacillin-resistant coagulase-negative Staphylococcus grew on POD9 and cefepimeresistant Stenotrophomonas maltophilia grew on POD18. An
emergent 2nd laparotomy was done. The bladder and distal
colon were found with adhesion at the previously perforated
site of the uterus. The necrotic area became putrid, whitish
and larger than previously at 30 mm in diameter. Supravaginal
hysterectomy (SVH), bilateral salpingo-oophorectomy (BSO),
and tube drainage were performed. The histological examination of the resected specimen revealed hemorrhagic necrosis
without evidence of malignancy. The intensive antibiotics
were continued, and she recovered uneventfully and was discharged on the 36th day after the first surgery.
Pyometra is a rare event in the general population but
more common in elderly women. The incidence is 0.5% in
gynecologic patients. However, it may rise to 13.6% among
elderly patients (1). The cause of pyometra is occlusion of
the cervical canal by malignant or benign tumors, surgery,
radiotherapy or senile cervicitis. A spontaneous perforation
of pyometra and subsequent diffuse peritonitis is rare, with
the incidence being about 0.01 - 0.05% (2). As the older population has been rising, peritonitis due to perforated pyometra
may be encountered more frequently. The risk factors might
include a decline in activity (1,3,4), incontinence (1,4), diabetes (5-9), and long-term IUD (10). It is well known that
IUDs can contribute to the development of serious pelvic
infections (11-16). The infection may occur in previously
healthy women who were fitted with an IUD, possibly by
ascending infection from the genital tract via the fallopian
tubes. The condition is usually accompanied by bilateral

Pyometra, a collection of purulent material in the uterus,

is an uncommon gynecologic entity. Spontaneous rupture of
pyometra is a rare cause of generalized peritonitis. Only
several cases have been reported in the English medical literature, some of which were associated with gynecological
malignancy. We treated a patient with generalized peritonitis
due to ruptured pyometra with an intrauterine device (IUD)
inserted for more than 20 years. No evidence of malignancy
or other cervical disease was found. Several features deserve
emphasis from the comparison with other published case
reports.
A 69-year-old woman visited the hospital presenting abdominal pain, fever episode, vomiting, and anorexia for one
day. For 2 weeks prior to admission, she also had preceding
purulent vaginal discharge. She did not have diabetes mellitus
and had never had sexually transmitted diseases. Four normal vaginal deliveries were reported without other operative
history. On physical examination, she looked acutely ill with
profound septic shock (body temperature 36.9C, pulse rate
73 beats per minute, and blood pressure 47/27 mmHg). Palpation of her abdomen was soft without distention. However,
general tenderness with muscular guarding was recognized.
The results of laboratory studies on admission revealed multiple organ failure. Computed tomography visualized an IUD
with free air. She was diagnosed with diffuse peritonitis and
a perforated gastrointestinal tract was suspected. Emergent
laparotomy was performed. At laparotomy, about 500 mL of
seropurulent fluid was encountered in the peritoneal cavity.
No abnormal findings were found in the gastrointestinal tract,
liver, or gallbladder, but a necrotic-black area (approximately
20 mm in diameter) was found at the anterior wall of the
uterus as well as perforation into the peritoneal cavity. The
IUD was removed and two rubber drainage tubes were placed.
Penicillin-resistant Bacteroides fragilis was isolated from the
pus. Sequencing of the bacterial 16S ribosomal RNA gene
identified the species.
Postoperatively, she received hemodialysis due to eleva*Corresponding author: Mailing address: Department of Obstetrics and Gynecology, National Taiwan University Hospital, No.
7, Chung-Shan South Road, Taipei, Taiwan, 100. Tel: +886-223123456 ext. 5167, Fax: +886-2-2751-2361, E-mail: p91421014
@ntu.edu.tw, dtobgya1@yahoo.com.tw
477

ing as generalized peritonitis. Postgrad. Med. J., 61, 645-646.

4. Iwase, F., Shimizu, H., Koike, H., et al. (2001): Spontaneously perforated
pyometra presenting as diffuse peritonitis in older females at nursing
homes. J. Am. Geriatr. Soc., 49, 95-96.
5. Imachi, M., Tanaka, S., Ishikawa, S., et al. (1993): Spontaneous perforation of pyometra presenting as generalized peritonitis in a patient with
cervical cancer. Gynecol. Oncol., 50, 384-388.
6. Sussman, A.-M., Boyd, C.-R., Christy, R.-S., et al. (1989): Pneumoperitoneum and an acute abdominal condition caused by spontaneous
perforation of a pyometra in an elderly woman: a case report. Surgery,
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7. Tsai, M.-S. and Wu, M.-H. (2006): Images in clinical medicine. Pneumoperitoneum due to spontaneously perforated pyometra. N. Engl. J. Med.,
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8. Geranpayeh, L., Fadaei-Araghi and M., Shakiba, B. (2006): Spontaneous
uterine perforation due to pyometra presenting as acute abdomen. Infect.
Dis. Obstet. Gynecol., 2006, 60276.
9. Tan, L.-K. and Busmanis, I. (2000): Spontaneous uterine perforation
from uterine infarction: a rare case of acute abdomen. Aust. N. Z. J.
Obstet. Gynaecol., 40, 210-212.
10. Guler, O.-T., Basaran, A., Guven, S., et al. (2007): Spontaneous uterine
perforation in an immunocompromised menopausal woman with pelvic
actinomycosis. Int. J. Gynaecol. Obstet., 99, 134-135.
11. Maloy, A.-L., Meier, F.-A. and Karl, R.-C. (1981): Fatal peritonitis following IUD-associated salpingitis. Obstet. Gynecol., 58, 397-398.
12. Goldman, J.-A., Yeshaya, A., Peleg, D., et al. (1986): Severe pneumococcal peritonitis complicating IUD: case report and review of the
literature. Obstet. Gynecol. Surv., 41, 672-674.
13. Lee, S.-L., Huang, L.-W., Seow, K.-M., et al. (2007): Spontaneous
perforation of a pyometra in a postmenopausal woman with untreated
cervical cancer and forgotten intrauterine device. Taiwan J. Obstet.
Gynecol., 46, 439-441.
14. Chen, Y.-W., Yang, Y.-C., Chen, C.-P., et al. (2007): Concomitant
Serratia marcescens peritonitis and tubo-ovarian abscess associated with
peritoneal dialysis and intrauterine device placement. Taiwan. J. Obstet.
Gynecol., 46, 429-430.
15. Gorsline, J.-C. and Osborne, N.-G. (1985): Management of the missing
intrauterine contraceptive device: report of a case. Am. J. Obstet.
Gynecol., 153, 228-229.
16. Goldman, J.-A., Peleg, D., Feldberg, D., et al. (1983): IUD appendicitis.
Eur. J. Obstet. Gynecol. Reprod. Biol., 15, 181-183.

salpingitis and may be severe with a fatal outcome. However,

spontaneous perforated pyometra related to IUDs have rarely
been reported. Suspected pathological factors are age-related
involution of the uterus, circulatory insufficiency, and decrease
of immunity against bacterial infections (1). The correct diagnosis has rarely been made preoperatively because the most
common presenting symptoms are abdominal pain, vomiting,
nausea, and fever of short duration. The most common
preoperative diagnosis is generalized peritonitis, pneumoperitoneum, and perforation of the gastrointestinal tract. Most
patients receive a hysterectomy, but the mortality rate is high.
In this case, we performed laparotomic peritoneal lavage with
drainage in the initial operation and SVH with BSO in the
next operation due to poor control of infection by antibiotics.
This shows that a hysterectomy might be the best choice for
a perforated pyometra.
In conclusion, the possibility of a perforated pyometra
should be considered when an elderly woman presents with
acute abdominal pain with an IUD. Removing the IUD is
mandatory in postmenopausal women. When peritonitis
caused by a perforated pyometra is actually diagnosed, emergency surgery is indicated. These patients are elderly and in
poor general condition. Intensive care with strict management
of respiration and circulation is essential. Their management
is often difficult, and hysterectomy with BSO may be the
best choice of procedure.
REFERENCES
1. Sawabe, M., Takubo, K., Esaki, Y., et al. (1995): Spontaneous uterine
perforation as a serious complication of pyometra in elderly females.
Aust. N. Z. J. Obstet. Gynaecol., 35, 87-91.
2. Gita, R., Jain, K. and Vaid, N.-B. (1995): Spontaneous rupture of pyometra. Int. J. Gynaecol. Obstet., 48, 111-112.
3. Hosking, S.-W. (1985): Spontaneous perforation of a pyometra present-

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