Pyometra secondary to colouterine fistula as a complication of diverticulitis
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IMAGES IN UROGYNECOLOGY
Pyometra secondary to colouterine fistula as a complication of diverticulitis Francisco Miguel González Valverde 1,2
&
María Jesús Gómez Ramos 1,2
Received: 30 June 2020 / Accepted: 14 October 2020 # The International Urogynecological Association 2020
Keywords Colouterine fistula . Diverticulitis . Diverticular abscess . Pyometra
Fistulae constitute a complex problem that involves up to 20% of the observed cases of diverticulitis [1, 2]. Colovesical fistula is the most common, whereas colouterine fistula (CUF) secondary to diverticulitis is a truly strange finding, owing to the thickness of the uterine wall [2, 3]. An 82-year-old woman, with a history of poorly controlled hypertensive cardiopathy, auricular fibrillation and esophageal achalasia was referred to the Emergency Department with abdominal pain and dysuria. The patient complained of bilateral loin pain and foul-smelling vaginal discharge that had lasted for 5 days. Abdominal examination revealed a large ovoid hypogastric mass without irritation signs. Her temperature was 37.9 °C, pulse rate was 89 beats/min and blood pressure was 160/90 mmHg. Blood analysis demonstrated leukocytosis (37,210/mm3, neutrophil fraction 86%), and anemia (hemoglobin 8.5 g/dl). The arterial blood gas values, at 40% FlO 2 , disclosed a PaO 2 of 94 mmHg, a PaCO 2 of 5 mmHg, a lactate level of 1.9 mmol and a pH value of 7.31. Urinalysis indicated urinary tract infection. Abdominal X-ray showed a radiolucent area in the hypogastrium (Fig. 1) produced by a large air bubble inside the uterus. Computed tomography (CT) showed a
paracolic abscess (Fig. 2), a CUF secondary to diverticulitis (the actual fistula site was visible on CT, Fig. 3), and a pyometra, joined to the thick sigmoid wall (Fig. 2). A barium enema confirmed extensive colonic diverticulosis with a fistula tract (Fig. 4). Because of her high surgical risk (ASA IV) the patient was treated conservatively with CT-guided percutaneous drainage of the paracolic abscess, transcervical–vaginal drainage of the pyometra, intravenous antibiotics (ceftriaxone plus metronidazole over 12 days) and total parenteral nutrition. The culture of the vaginal discharge grew Klebsiella pneumoniae and Escherichia coli. Her symptoms improved, the fistula closed spontaneously, and the patient refused a hysterectomy or other surgical procedure. Currently, 3 years later, she remains well.
* Francisco Miguel González Valverde [email protected] 1
Department of Surgery, Pediatrics and Obstetrics and Gynecology, University of Murcia, Murcia, Spain
2
General and Digestive Surgery service, Hospital General Universitario Reina Sofía de Murcia, Avenida Intendente Jorge Palacios. PC: 30003, Nº1, Murcia, Spain
Fig. 1 Abdominal X-ray demonstrates the presence of air within the fundus of the uterus (arrow)
Int Urogynecol J
Fig. 2 Abdominal CT scan (axial view) showing a sigmoid diverticulitis (arrow) associated with a paracolic abscess and b a dilated, medium air-filled cavity with some fluid located in the anterior aspect
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