Spontaneous Perforation of Pyometra in a Postmenopausal Woman with Intrauterine Device Presenting with Septic Shock:...

Pyometra is an uncommon gynecologic disorder characterized by the accumulation of pus within the uterine cavity typically resulting from cervical obstruction. Spontaneous perforation of pyometra (SPP) is extremely rare but may rapidly progress to generalized peritonitis and septic shock. We report a case of SPP in a postmenopausal woman initially misdiagnosed as gastrointestinal perforation and review the literature to highlight diagnostic pitfalls and management strategies.

A 69-year-old postmenopausal woman presented with acute abdominal pain, fever, vomiting, and septic shock. CT demonstrated pneumoperitoneum and ascites, suggestive of gastrointestinal perforation. An emergency laparotomy was performed, which identified a 4-cm perforation in the posterior uterine wall with purulent intraperitoneal fluid. Total hysterectomy with bilateral salpingo-oophorectomy and drainage was performed. Postoperatively, the patient developed respiratory failure but recovered and was discharged on postoperative day 28.

We conducted a retrospective analysis of 66 SPP cases identified from the published literature, encompassing cases from the first report in 1985 through 2025, with the present case included. Among the 63 patients with sufficient diagnostic data, the preoperative misdiagnosis rate was approximately 84%. Nonspecific gastrointestinal symptoms were the major cause of diagnostic delay. CT may be one of the more informative imaging modalities based on the available data. Total hysterectomy with adequate drainage could be considered a reasonable treatment option based on the available evidence. Among the 36 cases with microbiological data, 49 organisms were isolated; Enterobacteriaceae (22/49, 44.9%), anaerobes (17/49, 34.7%), and Gram-positive cocci (10/49, 20.4%) were the predominant pathogens. Among the 66 patients, survival data were clear for 63 cases, while data for the remaining 3 patients were unknown. The mortality rate was 25.4% (16 out of 63), which is similar to previously reported rates. Secondary wound healing occurred in 14.9% of survivors, and the median hospital stay was 20.5 days. One patient died intraoperatively from myocardial infarction, while 15 died postoperatively, mostly within 30 days. The leading cause of death was multiple organ failure, followed by sepsis and septic shock. The estimated 7-, 14-, 30- and 60-day survival rates were 86.9%, 84.6%, 72.4% and 52.8%, respectively.

SPP should be considered in the differential diagnosis for a postmenopausal woman presenting with acute abdomen and pneumoperitoneum. Early CT evaluation, prompt source-control surgery, and empirical antibiotics with coverage against Enterobacteriaceae and anaerobes are essential to reduce mortality. Antibiotic therapy should be guided by culture and susceptibility testing.