Inflammation of the female reproductive system is common; however, spontaneous uterine perforation due to purulent metritis and pyometra is clinically rare and thus easily overlooked or misdiagnosed. The older the age, the higher is the incidence; poor personal hygiene is the most common causative factor. Postmenopausal women have low oestrogen levels, along with reduced vaginal mucosal keratosis and decreased intracellular glycogen. Inhibiting the production of lactic acid weakens the self-purification effect of the vagina, decreases resistance to infection and causes infection. In addition, the cervix is atrophied, the cervical canal becomes narrow, adhesions easily occur, and the myometrium is atrophied and thinned. Therefore, inflammatory secretions cannot be drained in a timely manner or are not drained smoothly, causing intrauterine empyema, which increases pressure in the uterine cavity, erodes the thinned myometrium, and leads to tissue necrosis and perforation [2, 3].
When a patient sees a doctor due to fever, lower abdomen swelling, pain, and increased vaginal discharge, it is easier to reach a diagnosis by gynaecological examination and imaging examination. However, not all patients with empyema have typical symptoms. When treating digestive system symptoms, it is easily misdiagnosed as a perforation of the digestive tract in clinical practice, especially in elderly patients [4–8].
Elderly individuals are slow to respond and exhibit memory decline, and most of them cannot clearly describe their medical history. In addition, they exhibit low touch and pain thresholds and a poor response to inflammation. The clinical symptoms are more concealed, and the signs are not typical. Abdominal wall relaxation, abdominal muscle atrophy, fat thickening, and abdominal muscle tension are not obvious, and the symptoms and signs are less severe than the actual lesions. Moreover, elderly women rarely undergo gynaecological examinations, and the older they are, the fewer physical examinations they undergo. As a result, most elderly women cannot seek timely medical treatment when they are sick, consequently delaying diagnosis and treatment. The difference between uterine and gastrointestinal perforations can be distinguished by the following points: ① Carefully solicit the medical history. Uterine abscess perforation is more common in elderly menopausal women; the early symptoms are only increased leucorrhoea with lower abdominal pain, which is tolerable and thus not paid attention to, which delays recognition of the condition. However, most upper gastrointestinal perforations have a history of ulcers, most of which involve acute abdominal pain after eating or a sudden onset of abdominal pain; the starting point is mostly in the upper abdomen, from which the pain spreads rapidly to the whole abdomen, and the upper abdomen is more severe. ② Perform abdominal puncture. When the upper gastrointestinal tract is perforated, the extracted fluid will be a grass-green or yellow thin liquid that is odourless and mixed with food residues; microscopic examination reveals a small amount of pus. In contrast, the liquid extracted from a uterine abscess perforation is yellowish white, viscous, and malodourous; microscopic examination reveals pus throughout the full field of view. ③ If elderly female patients present a large amount of fluid in the abdominal cavity and free gas in the septum within a short period of time, perforation of the uterine abscess should be considered. In contrast, if perforation of the upper gastrointestinal tract has occurred, a large amount of fluid in the abdominal cavity is unlikely to accumulate within a short period of time.
At the same time, postmenopausal uterine inflammation should be differentiated from endometrial cancer, fallopian tube cancer, and cervical cancer. Because endometrial cancer is a tumour that is more common in elderly women, it often manifests as various types of uterine bleeding, abnormal vaginal discharge and pain. The lesions may be formed due to poor drainage in the lower uterus or invasion of the cervical canal. Haemorrhage or empyema may be present in the uterine cavity. The postoperative examination of the present patient showed a moderately differentiated squamous cell carcinoma of the cervix, indicating that when cervical tumours cause poor drainage of the cervical canal, they can also cause empyema and even perforation into the uterine cavity.
Elderly patients with pyometra and spontaneous uterine perforation show a rapid onset, rapid changes, and severe illness. If they are not treated in time, septic shock and multiple organ dysfunction may occur, and the original disease may even be life-threatening. According to the literature, the median age of rupture and perforation of empyema is 73.8 years; for elderly women with complicated diseases, the mortality rate is 25–40% [1, 6, 7, 9].
The principle of treatment of this disease is to carry out blood, body fluid or faecal bacterial culture and drug sensitivity tests on the basis of symptomatic and supportive therapy. Adequate and sensitive antibiotics and antifungal drugs should be provided. When intra-abdominal infection is suspected and the formation of an abscess is confirmed by examination, surgical exploration and drainage should be performed in a timely manner. Advanced age should not be considered a contraindication to surgery; however, elderly patients often have other diseases. In this population, surgery and anaesthesia are extremely risky, the perioperative condition changes drastically, and there is even a risk of death. Therefore, patients’ families should be informed in detail regarding possible complications during the perioperative period and be encouraged to consider surgical treatment. The surgery should have a short duration, incur minimal trauma, and involve simple and safe procedures.