Management of Pyometra Using a Novel Image-Guided Percutaneous Technique: A Case Report.

Pyometra is a uterine infection that causes pus to accumulate in the uterine cavity. Pyometra primarily affects postmenopausal women. Multiple aetiologies, including cervical stenosis, have been identified. Medical therapy using intravenous antibiotics and surgical evacuation are the conventional treatment options for pyometra. Here, we present a unique case of a novel therapy for pyometra in a geriatric patient; percutaneous alleviation of the causative cervical stenosis was performed using balloon dilatation, along with endometrial drainage of the infected fluid through her vagina, a natural route. This technique has overcome the need for other invasive therapies. The patient's clinical condition improved significantly after this minimally invasive treatment. Percutaneous balloon dilatation of the cervix for stenosis or occlusion in patients with pyometra facilitates drainage of the infected endometrial fluid. This alternative management technique ensured a satisfactory postoperative course and tolerance in the short-term follow-up. Furthermore, the technique ensured good aesthetic results, with its minimally invasive approach in selected patients, compared to other means of evacuation.

Stump Pyometra Secondary to Human Topical Estrogen Hormone Exposure in a Spayed Female Chihuahua.

A 6 yr old female spayed Chihuahua was presented for evaluation of intermittent vulvar discharge, stranguria, and vomiting. This dog had an ovariohysterectomy as a puppy and did not experience any evidence of estrous until 4.5 yr later. The owner had been using a topical hormone replacement therapy (estradiol spray) twice daily for the duration of the dog's clinical signs of 1 yr. On presentation, the dog had truncal alopecia, comedones, enlarged vulva with a malodorous, and purulent discharge. Bloodwork showed a leukocytosis with a neutrophilia, döhle bodies, and moderate toxic changes. An abdominal ultrasound revealed an enlarged uterine stump with a thickened wall, ovoid projection cranially, and echogenic luminal contents. An exploratory laparotomy identified an enlarged cervical stump. Histopathology revealed chronic suppurative vaginitis with endometritis, necrosis, and intraluminal coccoid bacteria. The dog recovered well from surgery. A baseline estrogen level post operatively was measured at 56.4 pg/mL (<50.0 pg/mL for a spayed bitch), at this time, the dog had been separated from the owner for 7 days. After surgery, the clinical signs disappeared, and the dog's dermatologic changes improved. This is the first reported case of stump pyometra following exposure to the owner's topical estradiol replacement medication.

A case of obstructed hemivagina and ipsilateral renal anomaly syndrome complicated with pyometra: tips and tricks for laparoscopic hemihysterectomy.

OBJECTIVE: To present a case of obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome complicated with pyometra and explain tips and tricks for laparoscopic hemihysterectomy. DESIGN: A step-by-step explanation of the technique with the use of video (Canadian Task Force Classification III). Patient consent and Institutional Review Board approval were obtained. SETTING: OHVIRA syndrome is characterized by the triad of uterovaginal duplication, obstructed hemivagina, and ipsilateral renal agenesis (1). Patients with OHVIRA syndrome usually present with dysmenorrhea and a vaginal or a pelvic mass. Renal, uterine, and vaginal pathologies can be diagnosed with the use of ultrasonography and magnetic resonance imaging (MRI) (2). In cases in which the diagnosis is not delayed, treatment consists of vaginal septostomy (3). Delayed diagnosis may lead to pelvic infections in patients with microperforations in the septum, which may lead to abscess formation, pelvic inflammatory disease, pyometra, and subsequent need for hemihysterectomy and adnexectomy (4). PATIENT(S): A 21-year-old G2 P2 patient who had a history of hospitalization with the diagnosis of tubo-ovarian abscess three times previously presented to the emergency department with pelvic pain, nausea, high fever, and malodorous vaginal discharge. On physical examination, a pelvic abscess draining to the left vaginal wall and a 10-12-cm left adnexal mass were noticed. A diagnosis of OHVIRA syndrome and pyometra was made after evaluation of ultrasonographic and MRI findings. Longitudinal vaginal septum excision and drainage of the abscess was performed. Ten cubic centimeters of purulent abscess material was drained by incising the left vaginal wall. However, the mass extending from the left vaginal wall to the left adnexal area could not be drained. On hysteroscopy, no cervix was visualized belonging to the obstructed hemivagina and the left uterine cavity could not be entered. On reexamination of the MR images, the presence of a transverse vaginal septum overlying the left hemivagina was detected, preventing access to the left hemiuterine cavity. The transverse vaginal septum could have been excised and the pyometra drained; however, owing to the presence of chronic pelvic pain and dyspareunia, and a history of three failed previous attempts at treatment, the decision to perform hemihysterectomy was made. INTERVENTION(S): A laparoscopic hemihysterectomy was performed in the patient, who was diagnosed as having OHVIRA syndrome complicated with pyometra. Patient consent and Institutional Review Board approval were obtained for this report. MAIN OUTCOME MEASURE(S): On laparoscopy, the left hemiuterus on the same side as the obstructed hemivagina appeared three to four times larger than the normal hemiuterus, in which two pregnancies had occurred, and dense adhesions were present between this hemiuterus and the bowel. The left hemiuterus was densely adherent to the pelvic side wall. Laparoscopic hemihysterectomy was performed. A monofilament barbed suture were used for the repair of the paracervical area and left hemivagina. A transverse septum and cervical atresia was noticed at the distal end of the left hemiuterus. The surgical challenges encountered during treatment of this case were the difficulty in recognizing anatomic structures owing to chronic inflammatory changes, dissecting dense adhesions without injuring neighboring pelvic organs, providing adequate hemostasis during dissection of fragile and hemorrhagic tissues, gaining optimal visualization of the surgical field owing to hampered hemostasis, obtaining adequate exposure of the surgical site owing to the inability to use a uterine manipulator, and the difficulty in dissecting the left hemiuterus without damaging the right hemiuterus for fertility preservation. The ultrasonic scalpel is an energy modality that is known to cause the least amount of collateral thermal tissue damage. In the present case, an ultrasonic scalpel was used to dissect dense adhesions between the left hemiuterus and the urinary bladder to minimize the risk of thermal injury to the urinary bladder. The ultrasonic scalpel was also used when dissecting the unhealthy hemiuterus from the healthy hemiuterus owing to its ergonomic tip and to avoid thermal damage to the cervix of the healthy hemiuterus. In areas of dense adhesions and distorted anatomy, the broad tips of bipolar forceps are also helpful for blunt dissection and the creation of tissue planes, and it is also used for effective concomitant hemostasis. A vessel sealer is the most appropriate energy modality for providing effective hemostasis during dissection of the uterine artery while causing minimal collateral tissue damage (5, 6). When deciding the kind of energy modality to be used during operative laparoscopy, the source that minimized thermal injury while providing optimal hemostasis was preferred. Furthermore, additional features such as rotation, dissection, grasping, and the ergonomics of the tip of the device were also considered when choosing the energy source to be used. RESULT(S): The patient was discharged 48 hours postoperatively with no complications. No symptoms of pelvic pain, dysmenorrhea, and dyspareunia were present at the end of the third month after surgery. CONCLUSION(S): Understanding the exact nature of the uterine anomaly before hemihysterectomy is of paramount importance for a successful surgery. Laparoscopy is a safe and effective treatment modality even in the presence of dense pelvic adhesions and distorted pelvic anatomy.

Cystic endometrial hyperplasia-pyometra syndrome in bitches: identification of hemodynamic, inflammatory, and cell proliferation changes.

Cystic endometrial hyperplasia (CEH)-pyometra syndrome is one of the most common diseases of noncastrated female dogs. However, determination of etiological mechanisms and differential diagnosis of CEH-pyometra syndrome are undefined. The aim of this study is to compare immunohistochemically the expression of cyclooxygenase-2 (COX-2) inflammatory mediator, Ki-67 antigen proliferation marker, vascular endothelial growth factor (VEGF-A) angiogenesis mediator and its FLT-1 and KDR receptors, and correlate with Doppler velocimetry of uterine artery and endometrial vascularization in bitches with CEH-pyometra syndrome. Bitches were allocated into CEH-mucometra Group (n = 13), Pyometra Group (n = 11), and Control Group (n = 8). Pyometra Group presented cytoplasmatic staining intensity for COX-2, VEGF-A, and FLT-1 and KDR receptors in luminal epithelium cells significantly higher compared to CEH-mucometra and Control groups. For the glandular epithelium, Pyometra Group had higher immunostaining score for VEGF-A and its receptors (FLT-1 and KDR). Hemodynamic indexes showed negative correlation with VEGF-A and its receptors as well as with COX-2. On the other hand, uterine vascularization score showed positive correlation in relation to immunostaining of COX-2, VEGF-A, and receptors in the endometrium luminal epithelium. In conclusion, uterus of bitches with CEH-pyometra syndrome show inflammatory process characterized by COX-2 expression, resulting in greater expression of proliferative Ki-67 marker as tissue response against the infectious agent. Furthermore, the increased VEGF-A expression and its receptors in CEH-pyometra reflect the increased blood flow and lower vascular resistance. Therefore, canine pyometra is characterized by an inflammatory, proliferative, and vascular disorder.

Cervical wedge resection for treatment of pyometra secondary to transluminal cervical adhesions in six mares.

CASE DESCRIPTION: 6 mares with pyometra secondary to transluminal cervical adhesions were examined. CLINICAL FINDINGS: Reasons for hospital admission included infertility (5 mares) and acute colic (1 mare). In the 6 mares, palpation per rectum of the reproductive tract revealed uterine distention, and transrectal ultrasonography confirmed the presence of echogenic fluid accumulation within the uterus. Cervical palpation during vaginal speculum examination indicated transluminal cervical adhesions. Three mares had severe distortion of the cervix as a result of diverticula and fibrosis. All 6 mares had a diagnosis of pyometra secondary to transluminal cervical adhesions. TREATMENT AND OUTCOME: Initially, the cervical adhesions were manually broken down to establish a patent cervical lumen to accommodate a uterine lavage catheter. A sample of the uterine content was obtained for bacteriologic culture and antimicrobial susceptibility testing, and the uterus was lavaged with 0.05% povidone-iodine solution to remove the mucopurulent exudate. Once the uterus was evacuated, cervical surgery was performed in standing mares following sedation and caudal epidural anesthesia. A full-thickness wedge-shaped defect was made in the dorsolateral aspect of the cervix that created a permanent opening to the uterus. Postoperative care included applying topical medication to the cervix to reduce the recurrence of adhesion formation. All 6 mares had patent cervices and resolution of pyometra following surgery. CONCLUSIONS AND CLINICAL RELEVANCE: Cervical wedge resection enabled treatment of pyometra in mares with transluminal cervical adhesions, without the need for ovariohysterectomy.

Pyometra in elderly post-menopausal women: a sign of malignity.

PURPOSE: To describe the clinical and histopathological characteristics of 12 patients with pyometra and highlight the increased incidence of gynecological malignancy in these patients. MATERIALS AND METHODS: The authors examined the medical records of 12 patients with pyometra, who were treated between 2009 and 2013. RESULTS: All patients were post-menopausal, and their mean age was 70.83 ± 6.978 years (min = 61, max = 82). To remove purulent fluid via dilation and because of the probability of malignancy, three patients (25%) underwent cervical biopsy and endometrial curettage; the other nine patients (75%) underwent curettage alone, with suitable antibiotic therapy. Of the 12 patients, nine (75%) had gynecologic malignancy [(endometrial cancer, n = 5, 41.6%), (cervical cancer, n = 3, 25%), (uterine leiomyosarcoma, n = 1, 8.3%)]. In three (25%) patients, the cause of pyometra was benign pathologies, among which the most common were leiomyomas (n = 2, 66.6%). CONCLUSION: Pyometra diagnosed during the post-menopausal period should be considered a complication caused by gynecological malignancy until proven otherwise.

The role of toll-like receptors 2 and 4 in the pathogenesis of feline pyometra.

Pyometra is the most common uterine disease in queens. To protect itself from infection, the female reproductive tract possesses several immune mechanisms that are based on germline-encoded pattern recognition receptors (toll-like receptors [TLRs]). The aim of our study was to examine endometrial immunolocalization of TLR2/4, study the influence of lipopolysaccharide (LPS) and tumor necrosis factor (TNF) α on messenger RNA expression of both receptors in pyometric queens, and compare these patterns between estrous cycling queens and those hormonally treated with medroxyprogesterone acetate (MPA). Thirty-six queens, ranging in age from 7 months to 11 years, were allocated into seven groups (anestrus, estrus, mid-diestrus and late diestrus, short-term and long-term hormonally treated queens, and pyometric queens). At the messenger RNA level, the real-time polymerase chain reaction was applied, whereas at the TLR2/4 protein level, the expression was tested by immunohistochemistry. In queens at estrus, gene expression of TLR2 was upregulated after stimulation of endometrial explants by TNF (P < 0.001) and by TNF together with the LPS (P < 0.01). Moreover, gene expression of TLR2 was significantly upregulated after stimulation by TNF (P < 0.001) and LPS (P < 0.01) explants derived from queens that had been long-term hormonally treated with MPA. Endometrial gene expression of TLR4 was significantly upregulated after incubation of explants with TNF (P < 0.001) in queens at estrus and with LPS (P < 0.05) in queens short-term hormonally treated with MPA. Immunolocalization reported that TLR2/4 receptors are mainly localized in the surface and glandular epithelia. These data show that short-term and especially long-term administration of progesterone derivatives impairs TLRs in the endometrial epithelium, presumably enabling pathogens to break through this first natural barrier and thereby increase the risk of pyometra development.

Diverticular disease of the colon presenting as pyometra: a case report.

INTRODUCTION: Pyometra can be caused by various etiologies. We present a rare case of diverticular disease of the colon presenting as pyometra. This type of presentation can be challenging even for an astute clinician. CASE PRESENTATION: A 74-year-old Caucasian woman with a history of pyometra was referred to our gynecology clinic as an urgent case. She was obese, diabetic and hypertensive. Due to the patient profile and the clinical presentation, clinicians were misled toward a diagnosis of possible endometrial cancer. After further investigations, she was found to have colouterine fistula secondary to a diverticular abscess of the sigmoid colon. CONCLUSIONS: Persistent vaginal discharge due to pyometra can be caused by diverticular disease of the colon. Clinicians should be aware of this important differential diagnosis.

Complications and pregnancy outcome following uterine compression suture for postpartum haemorrhage: a single centre experience.

In the treatment of postpartum haemorrhage from uterine atony, uterine compression sutures, such as the B-Lynch suture and its modifications have a role with the advantage of preservation of the uterus for fertility. There is however, a risk that apposition of the anterior and posterior walls of the uterus will impede drainage of lochia, resulting in undesirable complications. We undertook a five-year retrospective study of all women who underwent uterine compression sutures at the KK Women's and Children's Hospital, between 2008 and 2012. In total, 23 women had uterine compression sutures during the study period, of which, nineteen women managed to conserve their uterus. Our complication rate was 25%, which included persistent vaginal discharge, pyometra and endometritis. There were three conceptions, with two successful pregnancies. Our study shows uterine compression suture to be a safe and effective alternative to avoid hysterectomy with preservation of fertility at the time of major postpartum haemorrhage. The outcome of subsequent pregnancies is reassuring.

McKusick Kaufman syndrome, complications arising at puberty.

BACKGROUND: McKusick Kaufman Syndrome (MKS), a rare genetic condition, presents in the neonatal period with a classic triad of postaxial polydactyly, congenital heart disease, and hydrometrocolpos. The diagnosis is typically clinical, based on the presence of polydactyly and hydrometrocolpos. CASE: We report the case of a 13-year-old female, who was diagnosed with MKS in infancy and underwent vaginal reconstructive surgery for a urogenital sinus. She was lost to follow-up thereafter. She presented to our institution at age 13 with pyometra, pyosalpinx, and tubo-ovarian abscess due to a stenotic cervix obstructing menstrual outflow. SUMMARY AND CONCLUSION: Gynecologic follow-up is imperative in patients with history of vaginal reconstruction to monitor for hematometra from outflow obstruction to prevent life threatening secondary bacterial infections.

Leucocyte phagocytosis during the luteal phase in bitches.

Pyometra is a disease that affects a large proportion of intact bitches, and typically is seen during the latter half of dioestrus. Several factors contribute to the development of pyometra, including genetic factors, an infectious component (most often Escherichia coli), and hormonal factors. Hormones may act directly on the endometrium, and also affect the immune system. In dogs, the phagocytic ability has been shown to decrease with age, and ovarian hormones have also been shown to affect immune resistance. The aim of the present study was to examine whether phagocytosis by canine leucocytes varies significantly during the luteal phase. Eight bitches were followed by repeated blood sampling. Samples were taken at the calculated optimal day for mating (Day 1), and thereafter on days 8, 15 and 22 (early luteal phase) and 29, 43, 57 and 71 (late luteal phase). Blood was collected from the cephalic vein into EDTA tubes for leucocyte counts and heparinised tubes for testing of phagocytosis and oxidative burst using commercial kits and flow cytometry. The cell activity of the phagocyting leucocytes, expressed as mean fluorescence activity, MFI, was significantly lower during late luteal phase than during early luteal phase. The proportion of leucocytes that was induced to phagocyte did not differ significantly. The percentage of cells stimulated by E. coli to oxidative burst was significantly lower during late luteal phase. Their activity did not differ between the two periods. The number of cells stimulated to oxidative burst by a low stimulus was too low to evaluate, and leucocytes stimulated with the high stimulus did not vary in oxidative burst between the two periods. The changes in phagocytic activity and in the number of leucocytes that showed oxidative burst were not associated with any change in the proportion of different leucocytes. The decreased phagocytic capacity possibly contributes to the higher incidence of diseases such as pyometra during the latter part of the luteal phase.

A novel case of canine disseminated aspergillosis following mating.

An intact bitch with a history of mating was presented with severe lameness and a vulvar discharge. A mixed lytic, proliferative tibial lesion and open pyometra were diagnosed. Bone biopsy and uterine culture revealed disseminated aspergillosis. This is the first report of Aspergillus pyometra with dissemination following mating in the dog.