Pyometra is purulent endometritis, accompanied by accumulation and retention of purulent exudate in the uterine cavity. Pyometra is manifested by pronounced symptoms: temperature rise, intoxication, cramping pains in the lower abdomen, the appearance of pus-like whites with an odor. The algorithm for diagnosing purulent endometritis involves gynecological examination, probing of the uterine cavity, ultrasound examination, hysteroscopy, bacteriological seeding of secretions. Treatment of pyometra requires the elimination of blockage of the cervical canal, evacuation of pus and sanitation of the uterine cavity, the appointment of antibacterial drugs, infusion therapy, uterotonics.
Pyometra is a local accumulation of pus–like contents in the uterus. The conditions for the occurrence of pyometra are the presence of purulent microflora in the uterine cavity and a violation of the evacuation of purulent exudate due to obstruction of the cervical canal. In gynecology, pyometra is synonymous with purulent endometritis and purulent metroendometritis. Pathology is more often diagnosed in women of childbearing and menopausal age, which is closely related to the etiology of pyometra: in the first group of patients, it usually develops as a complication of the postpartum or post–abortion period, in the second – as a complication of endometrial cancer in the decay phase. The consequences of pyometra can endanger reproductive plans (infertility) and even life (septic complications).
To form a pyometer, the following factors are necessary: blockage of the cervical canal, which prevents the outflow of cervical and uterine contents, and the addition of a secondary infection, due to which the accumulated secret (mucus, serous exudate, blood) is transformed into pus.
Obstruction of the cervical canal can be caused by various pathologies that create a mechanical obstacle to the evacuation of contents from the uterine cavity: cervical polyps, uterine fibroids (especially those located near the inner pharynx), the emerging submucous node, the proliferation of endometrioid foci. Possible blockage of the cervical canal by a foreign body, a displaced intrauterine spiral, a fragment of the fetal egg (after abortion) or placental tissue (after childbirth), blood clots. Often, pyometra serves as one of the symptoms of cervical and uterine body cancer in the decay phase. Cicatricial stenosis, developed as a result of radiation therapy or aggressive surgical manipulations (abortions, SDC, hysteroscopy) can also deform and narrow the lumen of the cervical canal. In old age, pyometra can develop against the background of atrophic stenosis of the cervical canal.
However, sometimes pyometra occurs without stenosis and occlusion. In these cases, the mechanism of pathology development may be associated with functional causes: cervical spasm (often occurs after abortion), hypotension or uterine atony (occurs against the background of complicated labor).
The most common background conditions preceding the formation of a pyometer are hematometer, lochiometra, post-abortion or postpartum endometritis. The secretions accumulated in the uterine cavity and not having outflow are easily infected with pyogenic microflora: streptococci, staphylococci, E. coli, which penetrate into the uterine cavity in an ascending way (during gynecological manipulations) or in a descending way (with adnexitis).
In its classic version, the pyometer is accompanied by vivid clinical signs. There are intense cramping pains in the lower abdomen, abundant purulent discharge from the vagina with a putrid odor, symptoms of purulent intoxication (high fever, malaise, chills). Palpation of the abdomen determines a painful tumor-like formation in the pelvic region. Pyometra can be suspected in the case of a decrease or complete cessation of secretions on the first day after abortion or childbirth. However, this pattern occurs only in half of the cases of pyometers.
Quite often, especially in old age, the pyometer has an erased course. In these cases, subfebrility is noted, purulent white spots appear from time to time, associated with periodic emptying of the uterine cavity. Sometimes pyometra is asymptomatic and is detected during ultrasound or autopsy.
If pyometra develops against the background of endometrial cancer, the patient is concerned about progressive pelvic pain with irradiation to the lower extremities, purulent discharge with an admixture of blood, indicating a neglected malignant process and the collapse of the tumor.
At the initial consultation, the gynecologist is interested in the patient’s complaints and anamnesis of the present disease (how long ago the pathological symptoms appeared, whether they are related to childbirth, abortion, known gynecological diseases). During the examination on the chair with the help of vaginal mirrors, scanty or abundant purulent discharge from the cervical canal can be detected. With a bimanual examination, an enlarged, spherical shape and a testy consistency, painful uterus is determined. Senile pyometra is characterized by age-related atrophic changes in the vaginal mucosa, shortening or smoothing of the cervix, atresia of the external opening of the cervical canal.
During diagnostic probing of the uterine cavity or its catheterization, pus flows out. In this case, the diagnosis of pyometra is no longer in doubt. The resulting secretions are subject to bacteriological examination in order to identify the pathogen and obtain an antibioticogram.
Ultrasound of the pelvic organs allows you to identify the causes of obstruction of the cervical canal with a pyometer: fibroids, polyps, endometriosis, fragments of the fetus or placenta, etc. Hysteroscopy is performed to examine the uterine cavity from the inside. When receiving data for endometrial cancer, it is necessary to perform separate diagnostic curettage of the uterine cavity and the cervical canal or endometrial biopsy.
The diagnosis of pyometra is an absolute indication for the hospitalization of the patient. The primary tasks are: elimination of obstruction of the cervical canal, evacuation of the contents and sanitation of the uterine cavity. If the cause of the pyometra was a delay in the uterine cavity of the remnants of placental tissue or parts of the fetus, curettage is performed with subsequent washing of the uterine cavity with antiseptic solutions. The polyps of the cervical canal are surgically removed. With a combination of pyometra and fibroids in young women, they try to limit themselves to conservative myomectomy, but with diffuse purulent inflammation of the uterus and the impossibility of organ-preserving intervention, they resort to radical removal of the uterus: hysterectomy or supravaginal amputation. In endometrial cancer, the possibilities of surgical treatment are determined by the operability of the process.
After eliminating the purulent focus and the immediate cause of pyometra, parenteral administration of broad-spectrum antibiotics, detoxification infusion therapy is prescribed. Along with etiotropic therapy, vitamins, immunostimulants, antispasmodic and uterotonic agents are prescribed. After the completion of antibiotic therapy, physiotherapy procedures are prescribed to prevent the formation of intrauterine adhesions. The duration of the treatment and rehabilitation course can reach 1-3 months.
Prognosis and prevention
In case of inadequate or untimely start of pyometra treatment, life-threatening complications may occur: pelvioperitonitis, peritonitis, sepsis. The transferred pyometra in the future may cause miscarriage or uterine infertility.
The prevention of purulent endometritis is facilitated by competent pregnancy planning and the exclusion of abortions, vaginal sanitation before intrauterine manipulations and preventive administration of antibiotics after they are performed, monitoring of a woman in the post-abortion and postpartum period, timely treatment of infectious and inflammatory gynecological pathology (vulvovaginitis, salpingoophoritis, endometritis, etc.). Prevention of endometrial cancer consists in regular visits to a gynecologist and conducting ultrasound diagnostics.