CASE REPORT

A case of pyometra treated with endoscopic ultrasound-guideddrainage

Hideki Ishikawa • Tomomasa Morishima •

Takashi Seino • Hiroyuki Otuka • Hideaki Kondo •

Akihiro Itoh • Hidemi Goto • Yoshiki Hirooka

Received: 24 September 2011 / Accepted: 4 November 2011 / Published online: 12 January 2012

� The Japan Society of Ultrasonics in Medicine 2012

Abstract A 90-year-old woman was admitted to our

hospital because of a high-grade fever and appetite loss. On

computed tomography scan, a huge cystic lesion about

10 cm in diameter was observed in the pelvic cavity,

attached to the vagina and the neck of uterus. Pyometra

was strongly suspected; however, a probe could not be

inserted into the opening of the uterus because of atrophic

changes. Therefore, we decided to perform endoscopic

ultrasound (EUS)-guided drainage of the pyometra using

the transrectal route. Foul-smelling yellow–brown pus was

aspirated. A guide-wire was inserted and a 7 Fr catheter

was inserted into the pyometra through an external fistula.

We thus completed the treatment of pyometra without

surgical resection.

Keywords Pyometra � Endoscopic ultrasound-guided

fine-needle aspiration � Drainage � Interventional

endoscopic ultrasound

Introduction

The overall disease rate of pyometra in gynecological

patients is reported to be between 0.01 and 0.5% but the

rate in women over 60 years old increases to 13.6%.

Abnormal free air in the abdominal cavity has been found

in approximately 50% of cases in previous reports, and

many cases of pyometra have been misdiagnosed as per-

foration of the gastrointestinal (GI) tract. Transvaginal

uterine irrigation, drainage, and intravenous injection of

antibiotics are indicated for treatment of pyometra if no

perforation is detected. In many cases, emergency

abdominal total hysterectomy is performed because of the

risk of malignancy. This is the first case of pyometra suc-

cessfully treated using endoscopic ultrasound (EUS)-gui-

ded drainage without surgical resection.

Case report

A 90-year-old woman was admitted to our hospital on 19

July 2010 with a high-grade fever of 39�C and appetite loss

that had started 4 days previously. No symptoms of respi-

ratory disease, such as coughing, sputum production, or

abdominal pain were present. The laboratory data on

admission included signs of infection in the blood (white

blood cell count [WBC] 11800/ll, neutrophilia 85%) and in

urinalysis (C-reactive protein [CRP] 5.55 mg/dl). The cause

of the fever was unknown and so intravenous injection of

antibiotics was started on admission. However, the antibi-

otics had no antifebrile effect and the laboratory test results

worsened to WBC 18700/ll and CRP 7.18 mg/dl. We

therefore performed an enhanced abdominal computed

tomography (CT) scan, which revealed a huge cystic lesion

about 10 cm in diameter in the pelvic cavity attached to

H. Ishikawa � T. Morishima � T. Seino � H. Otuka

Department of Endoscopy and Gastroenterology, Tokai Central

Hospital of the Mutual Aid Association of Public School

Teachers, Gifu, Japan

H. Kondo

Department of Obstetrics and Gynecology, Tokai Central

Hospital of the Mutual Aid Association of Public School

Teachers, Gifu, Japan

A. Itoh � H. Goto

Department of Gastroenterology, Nagoya University Graduate

School of Medicine, Nagoya, Japan

Y. Hirooka (&)

Department of Endoscopy, Nagoya University Hospital,

65 Tsuruma, Showa, Nagoya 466-8550, Japan

e-mail: hirooka@med.nagoya-u.ac.jp

123

J Med Ultrasonics (2012) 39:93–96

DOI 10.1007/s10396-011-0340-9

both the vagina and the neck of the uterus, with an air

component and niveau formation. Suspecting a pelvic

abscess, we consulted a gynecologist who found, on trans-

rectal EUS, that the uterus was filled by an abscess with a

heterogeneous echo (Fig. 1); pyometra was strongly sus-

pected on the basis of the MRI appearance (Fig. 2). A probe

could not be inserted into the opening of the uterus because

of atrophic changes, and so the treatment plan for the

pyometra, selected by the gynecologist, was to perform an

open abdominal hysterectomy at another hospital, since a

few reports indicated the coexistence of a malignancy.

Because of the patient’s advanced age, grade 3 performance

status, and dementia, her family did not want a laparotomy

to be performed, and therefore we decided to carry out

EUS-guided drainage of the pyometra on 27 July 2011,

using the transrectal route. Clearly informed consent was

obtained before the procedure.

A GF-UCT240 echoendoscope (Olympus, Tokyo, Japan)

was inserted into the rectum, and observations were made in

color Doppler and power Doppler modes. However, no

Doppler signal was observed in the pyometra. The intra-

pyometric echogenicity was heterogeneous. To exclude the

possible existence of a tumorous lesion, enhanced EUS was

performed using Sonazoid� as the ultrasound contrast

agent, and, since no enhancement was observed around the

targeted area, it was concluded that a tumorous lesion was

present.

With the lower rectum in the position for stability of the

EUS scope, we flushed the rectal wall with saline, and

punctured it with a 19-gauge EchoTip Ultra (Wilson-Cook,

Winston-Salem, USA) under EUS guidance. Foul-smelling

yellow–brown pus was aspirated, and we then injected a

contrast agent into the pyometra under radiographic guid-

ance to confirm its location (Fig. 3). We then inserted a

0.025-inch guide-wire (VisiGlideTM OLYMPUS, Tokyo,

Japan). A Soehendra biliary dilation catheter (Wilson-

Cook, Winston-Salem, USA, 4–7 Fr) was used to enlarge

the puncture hole; however, this was difficult because of

the hardness of the uterine wall. Although the uterine wall

was 5 mm thick, no uterine wall dilation had been carried

out before the procedure. Once the puncture hole had been

dilated, a 7 Fr nasal biliary drainage catheter (Wilson-

Cook, Winston-Salem, USA) was inserted into the pyo-

metra with an external fistula (Fig. 4).

Pus drainage reached 800 ml a few days after this, and

the patient was afebrile from the day after drainage. After

six days of drainage, on 1 August, laboratory tests had

Fig. 1 Transrectal endoscopic ultrasonography showed that the

uterus was filled with an abscess with a heterogeneous echo; no

Doppler signal was measured in the pyometra

Fig. 2 A huge cystic lesion of about 10 cm was observed in the

pelvic cavity attached to both the vagina and the neck of uterus with

an air component and niveau formation

Fig. 3 With the lower rectum in a position providing a stable EUS

scope, we punctured the rectal wall with a 19-gauge EchoTip Ultra

under EUS guidance and injected contrast agent into the pyometra

under radiographic guidance to confirm its location

94 J Med Ultrasonics (2012) 39:93–96

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normalized to WBC 7410/ll and CRP 0.84 mg/dl, and

intravenous injection of antibiotics was discontinued. On

the same day, the pyometra disappeared from the abdom-

inal CT (Fig. 5). Bacterial pus culture showed combined

infection with the Enterococcus faecalis and Bacteroides

ureolyticus; the blood and urine cultures were negative.

We found no previous reports on the procedure for

catheter removal in this situation. The day on which pus

disappeared from the drainage tube, 10 August, we

performed a radiographic contrast study and removed the

drainage catheter carefully without leakage.

The treatment of the pyometra was now complete after

catheter retention for 15 days; no sign of recurrence has

been observed.

Discussion

Pyometra is caused by obstruction of the vagina and neck

of the uterus, and can interfere with uterine emptying,

resulting in the collection of pus in the uterine lumen. This

condition has been reported to be causally related to

malignancy in the uterus, colon cancer, a history of surgery

of the uterine cervix, radiation, senile atrophy, stenosis of

the neck of the uterus, and infection due to puerperium [1].

Increased age is associated with higher disease rates, and

this phenomenon is reportedly associated with inconti-

nence and decreased activies of daily living (ADL) [3].

Although typical symptoms include postmenopausal ovar-

ian dysfunction, uterine bleeding, festering leucorrhea, and

lower abdominal pain, a few cases have no symptoms or

have only fever of unknown origin. Moreover, pyometra

sometimes causes onset of acute abdomen [2, 4].

It has been reported that an abdominal CT scan is useful

for the diagnosis of pyometra, which presents as swelling

of the uterus, with liquid materials and air patterns in the

uterus. Abnormal free air in the abdominal cavity was

found in approximately 50% of cases in previous reports,

and many cases were misdiagnosed as perforation of the GI

tract [5]. Nishimura et al. [6] reported that the accuracy of

preoperative diagnosis of pyometra was only 22%. The

causes of bacterial infection were reported to be anaerobic

bacteria, such as Bacteroides fragilis and Peptostrepto-

coccus anaerobius, or aerobic bacteria, such as Escherichia

coli and Streptococcus spp. [7], and a few cases have

involved a combination of anaerobic and aerobic bacteria.

The air produced in the uterus, caused by a gas-producing

bacterium such as Bacteroides fragilis, is observed as

abnormal free air in the abdominal cavity.

The usual treatment for pyometra, if no perforation is

detected, is transvaginal uterine irrigation, drainage, and

intravenous injection of antibiotics. In many cases, emer-

gency abdominal total hysterectomy is performed because

of the risk of malignancy [2, 5]. Many studies of pyometra

have been reported by surgeons, and it has been suggested

that the low level of accuracy of diagnosis of pyometra

preoperatively comes from a lack of knowledge of the

disease on the part of surgeons [8].

In our case, the reason for the external fistula was to

avoid retrograde infection from the rectal mucosa.

This is the first case of EUS-guided drainage of pyo-

metra using the transrectal route to be reported.

Fig. 4 Foul-smelling yellow–brown pus was aspirated, and a 7 Fr

nasal biliary drainage catheter was inserted into the pyometra with an

external fistula

Fig. 5 On abdominal CT after 6 days drainage, the pyometra had

disappeared

J Med Ultrasonics (2012) 39:93–96 95

123

In this case, before EUS-guided drainage, we felt that

there was no tumorous lesion present because no color/

power Doppler flow and no enhancement by enhanced EUS

was observed around the target area. It was therefore

possible to avoid hysterectomy and, instead, we performed

EUS-guided drainage of the pyometra via the transrectal

route.

The incidence of cases of pyometra may increase in our

aging society and we should select minimally invasive and

safer procedures for elderly people, such as this patient.

Finally, as in this case, EUS-guided drainage can be a

useful and minimally invasive method to treat pyometra

when transvaginal drainage is impossible [9, 10].

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