An 84-year-old female was referred to emergency department with complaints of abdominal pain, fever, and vomiting. Her medical history included hypertension. Her abdomen was distended with involuntary guarding and rigidity. Laboratory findings indicated severe sepsis. Abdominal computed tomography revealed intraperitoneal air and a cystic mass abutting the uterus (Fig. 1). A radiologist suspected generalized peritonitis secondary to gastrointestinal perforation. During emergency laparotomy, we identified the perforation with the necrotic area at the uterine fundus (Fig. 2A). No gastrointestinal perforations were observed. She underwent a supra-cervical hysterectomy. A histopathological examination of the resected specimen revealed pyometra with ischemic necrosis of the endometrium infiltrated with inflammatory cells and no malignancy (Fig. 2B). She was discharged on postoperative day 18 and advised to follow-up.
Pyometra, a rare entity, involves the collection of pus in the uterine cavity. It occurs most often in postmenopausal females and may be caused by an obstruction of the cervical canal, usually secondary to malignant cervical lesions [1]. Spontaneously perforated pyometra are difficult to diagnose clinically. Misdiagnoses are common because of its rarity and non-specific symptoms. Once ruptured, an acute abdomen often develops with symptoms. However, more than 50% of cases are asymptomatic [2]. The most frequent preoperative diagnosis is generalized peritonitis secondary to gastrointestinal perforation. The confirmed diagnosis of spontaneously ruptured pyometra is made by laparotomy [3]. With diffuse peritonitis, perforated pyometra should be considered in the differential diagnosis of females who present with generalized peritonitis, particularly elderly.
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