Dr.Uma Gupta MD,FICMCH.

1
Pyometra Diagnosis and Management

• Dr.Uma Gupta MD,FICMCH.
• Associate Professor,Dept of Obstetrics
  Gynecology Eras Lucknow Medical College.Lucknow
• umankgupta_at_yahoo.com
• Dr.N.K.Gupta,MS,M.Ch.
• Professor,Dept of Surgery,Eras Lucknow Medical
  College.Lucknow.
• drnkgupta2000_at_yahoo.com

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Pyometra History

• Definition Accumulation of pus in uterine
  cavity, caused by interference with natural
  drainage of uterus is pyometra.
• First case was described by John Clarke of
  London in 1812. Attention was drawn by Whiteley
  and Hemlat l (1971) of more frequent association
  of pyometra with benign as compared to malignant
  disease of genital tract.
• Diversity in methods of management of these
  cases indicate that a logical approach is needed
  for their management.
• Attention is focused to review on etiology,
  improving clinical diagnosis, applying newer
  technology and early diagnosis.

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Etiology of pyometra

• Senile Endometritis
• Malignant-endometrial carcinoma
• Ednocervical carcinoma
• Ectocervical carcinoma
• Previous gynae surgery
• Obstetrical puerperal sepsis
• Foreign body (IUCD)
• Others
• Radiation effect for uterine carcinoma
• Tubercular endometritis
• Uterovaginal prolapse
• Submucous fibroid polyp

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Newer mechanisms

• Detection of pyometra after ovum retrieval for
  IVF with the routine use of ultrasound-guided
  embryo transfer.
• (Fertil Steril 2004 Apr81(4) 1156(4) author
  reply 1156-7.)

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contd.. Etiology of pyometra

• It can also occur secondary to intrauterine
  infection. Actinomycotic pyometra has been
  reported as a complication of a forgotten
  intra-uterine device. Recently there has been an
  increase in genital tuberculosis, and this
  occasionally presents with pyometra.

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Pathogenesis

• Association with squamous metaplasia of
  endometrium - reported with varying frequency. It
  may precede squamous carcinoma of endometrium.
• Pyometra chiefly appears to be result of
  malignancy as cervical canal is blocked by big
  tumor growth or presence of big necrotic growth
  in endometrium itself predisposes to formation of
  pyometra.

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Pyometra

• After menopause, when endometrium loses its
  resistance - not shed repeatedly, infection which
  gains entrance to uterus persists as senile
  endometritis.
• The pus which tends to collect in uterus forms
  pyometra, as cervix is narrowed by senile change
  atrophied myometrium unable to expel it.
• Hysterectomy is recommended in pyometra due to
  senile endometritis.

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Pyometra

• In cases where surgery is not done for various
  reasons, cyclic oestrogen therapy has definitely
  shown to reduce the risk of recurrence of
  pyometra.
• Oestrogen therapy helps in healing of senile
  endometritis lesion thus preventing recurrence of
  pyometra.

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Differential Diagnosis

• Uterine
• Leiomyomata
• Adenomyosis
• Adenomyoma
• Stromatosis
• Hemangiopericytoma

• Endometrial
• Polyps
• Endometrial cancer
• Adenomatoid tumor
• Plexiform tumorlet
• Lipoma
• Vascular tumors
• Hematometra
• Pyometra
• Hydrometra
• Gestational trophoblastic neoplasia
• Congenital abnormalities

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Investigations

• Vaginal swabs may be negative in up to 50 of
  cases, since the principle organisms are
  anaerobes and these are difficult to culture.
• If tuberculosis is suspected, tuberculin testing,
  culture, histology, hysterosalpingogram and
  nucleic acid amplification testing may be
  indicated.

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Contd.Investigations

• The mainstay of investigation is imaging.
  Ultrasound scanning has been employed for over 20
  years, and remains the chosen modality in most
  cases.
• It can also complicate endometrial carcinoma and
  Doppler scanning may be used to detect blood flow
  changes in this event.

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Pyometra

• Diagnostic USG to gynaecological field makes
  correct diagnosis.
• Frequent association of pyometra with uterine
  malignancy reported.
• CT scanning seems as sensitive to ultrasound, but
  the latter is often easier to access.

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Management

• Most women are treated with dilation of the
  cervix and drainage, with regular monitoring to
  detect recurrent or persistent disease.
  Antibiotics are only necessary if there is
  evidence of invasive infection, in the form of
  generalized malaise, pyrexia, or altered
  laboratory parameters.
• If antibiotics have to be used, preparations
  covering aerobic and also anaerobic bacteria
  should be used,
• Current research is focused on a group of drugs
  called carbapanems, which have an exceptionally
  wide spectrum of activity.Tubercular pyometra
  should be treated with appropriate
  anti-tubercular chemotherapy.

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Primary Treatment

• Drainage of pus by repeat dilatations, usually
  done biweekly or putting a Foleys
  catheter/drainage tube followed by curettage
  under antibiotic was the primary treatment.
• Time required for drainage of pus was found to be
  significantly shortened in cases of foleys
  catheter tube were inserted into the uterine
  cavity. Pus around 15-500 ml average of 65 ml
  collects.

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Secondary Treatment

• When cause of pyometra was malignant or other
  specific disease management is as per case.
• Management of pyometra because of senile
  endometritis Panhysterectomy within one month
  under routine antibiotic coverage. Those not fit
  for surgery medical management by prolonged
  cyclic oestrogen therapy (premarine0.625 mgm
  daily) for 4-6 months.
• Recurrences occur 2-11 months.

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Prognosis

• The prognosis in pyometra will depend both on the
  underlying cause (e.g. malignancy) and of the
  possibility of spontaneous perforation. Prompt
  recognition and treatment of the condition
  improves the prognosis considerably.