Clinical Presentation of Canine Pyometra and Mucometra

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Theriogenology 70 (2008) 359–363 www.theriojournal.com

Clinical presentation of canine pyometra and mucometra: A review S.D. Pretzer *  Abilene Animal Hospital, P.A., 320 NE 14th Street, Abilene, KS 67410, USA

Abstract

Cystic endometrial hyperplasia (CEH) in the bitch can result in either pyometra, hematometra, or hydrometra, and many facets of these uterine diseases can make them difficult to differentiate. The conditions differ in their systemic effects, since pyometra, particul particularly arly closed-c closed-cervi ervix x pyometr pyometra, a, can be a life-thre life-threaten atening ing condition condition that must must be recogniz recognized, ed, managed managed,, and treated treated expeditiously. Mucometra is an accumulation of sterile intraluminal mucoid fluid, hematometra is an accumulation of sterile, bloody fluid, and hydrometra is an accumulation of sterile, watery fluid; none of which have any significant systemic outward clinical signs. This paper will describe the definitions, signalment, historical findings, incidence, clinical signs, physical exam findings, and diagnostic findings in canine pyometra and mucometra, and hematometra and hydrometra. # 2008 Elsevier Inc. All rights reserved. Keywords: Pyometra; Mucometra; Cystic endometrial hyperplasia; CEH; Uterus

1. Introducti Introduction on

2. Definition Definition

Canine pyometra pyometra is a disease of intact bitches that is of particular importance to the veterinary practitioner, sinc sincee earl early y recog recognit nition ion,, diagn diagnos osis is and and approp appropria riate te inte interve rventi ntion on is requ require ired d to avoi avoid d disas disastro trous us conse conse-quences. Closed-cervix pyometra is particularly dangerous, because septicemia and toxemia may develop rapidly and left untreated can result in patient death. Although mucometra, hematometra, hematometra, and hydrometra hydrometra by them themse selv lves es are are not fatal fatal dise diseas ases es,, they they mu must st be differentiated from pyometra. Several diagnostic aids are available to assist assist in diagnosing diagnosing and differentiating differentiating pyometra, mucometra, hematometra, and hydrometra. For the purposes of this discussion, the conditions of  hematometra hematometra and hydrometra hydrometra can be used interchangeinterchangeably with mucometra, unless otherwise noted.

Pyom Pyometr etra, a, by definit definitio ion, n, is the the accu accumul mulati ation on of  purulen purulentt materia materiall within within the uterine uterine lumen of intact intact bitches bitches,, typical typically ly occurrin occurring g during during or immedia immediately tely following following a period of progesterone progesterone dominance. Historicall cally y, it has been been thoug thought ht suba subacut cutee endom endomet etrit ritis is is followe followed d by cystic cystic endome endometria triall hyperpl hyperplasi asiaa (CEH) (CEH) which which then predisp predisposes oses bitches bitches to develo develop p pyometra pyometra [1,2].. Others suggest that, due to differences in clinical [1,2] and histopa histopathol thologic ogic findings findings,, CEH and pyometra pyometra should should be classi classified fied separa separately tely [3] [3].. It is com omm mon to see pyometr pyometraa defined defined as the endome endometrit tritis/c is/cyst ystic ic endometr endometrial ial hyperplasia/pyometra complex (CEH/P) [4] [4].. Pyometra is classically a disease of the diestrual bitch and can be classi classified fied as open-cer open-cervix vix or closed-c closed-cervi ervix, x, with the latt latter er being being a medic medical al emerg emergen ency cy requi requirin ring g rapid rapid intervention to prevent subsequent sepsis and potential patient death [5] [5].. Mucometra, hematometra, or hydrometra are thought to occur with CEH, and the character

* Tel.: +1 785 263 2301; fax: +1 785 263 2925. E-mail address: [email protected] [email protected].. 0093-691X/$ – see front matter # 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.theriogenology.2008.04.028 doi:10.1016/j.theriogenology.2008.04.028

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of the intrauterine fluid differs from pyometra in that they they are are clas classi sica call lly y all all ster steril ilee and and are are the the fluid fluid is seromucous, seromucous, bloody, bloody, or serous, serous, respectively respectively [3] [3].. 3. Signalm Signalment ent and history

Pyometra typically affects mature bitches that have undergone undergone repeated repeated estrous estrous cycling, cycling, with a reported reported mean age age of 7.25 7.25 year yearss [6] [6].. Report Reported ed ages ages for bitche bitchess diagno diagnosed sed with with pyom pyomet etra ra rang rangee from from as youn young g as 4 mo mont nths hs to as old old as 16 years of age [7–16] [7–16].. In a group of 192 bitches bitches that were were treate treated d medic medicall ally y for pyome pyometra tra,, the mean mean age repor reporte ted d was was 2.4 2.4 year yearss [17] [17].. Histo Histori rica call even events ts of  importance in evaluation of a diestrual, intact bitch for pyomet pyometra ra includ includee prior prior treatm treatment ent with with estrog estrogens ens or progestins progestins,, whelping whelping history history,, and date of last estrous cycle. There appears to be an increased incidence of  pyometra in both nulliparous bitches and bitches greater than 4 years of age [18] [18].. Prior reviews indicate that nulliparous bitches comprise approximately 75% of the bitches with pyometra [1,8] [1,8].. Hormonal therapies that include either progestins for estrus suppression or estrogens for estrus induction or pregnancy termination may explain the development of pyometra in young bitches [12,19,20].. Youngbitch [12,19,20] oung bitches es with anatomic anatomicabnorm abnormaliti alities es of  the vagina and vestibule, such as strictures and septums, may be predisposed to develop these conditions. Some breeds reported to be predisposed to pyometra includ includee the Rottwe Rottweile iler, r, Saint Saint Bernar Bernard, d, Chow Chow Chow Chow, Golden Golden Retrieve Retriever, r, Miniature Miniature Schnauze Schnauzer, r, Irish Terrier, errier, Airedale Terrier, Cavalier King Charles Spaniel, Rough Collie, and Bernese Mountain dog [5,21] [5,21].. Breeds with a low low risk risk for pyomet pyometra ra includ includee Drever Drevers, s, German German Shephe Shepherd rd dogs, dogs, Daschu Daschunds nds,, and Swedis Swedish h hounds hounds [22] [22].. Other Other studies have shown no breed disposition [9,12] [9,12].. Most bitches present with pyometra within 12 weeks after the onset of the previous estrus, with a reported mean of 5.7 weeks. However, pyometra may occur at any stage of the estrous cycle or during pregnancy [6] [6].. Near Nearly ly thre threee-fo four urth thss of bitc bitche hess in anot anothe herr stud study y presented within 8 weeks of completion of the prior estrus [23] [23].. No association has been shown between false pregnancy and pyometra [13] [13].. Pyometra should always be considered in the differential diagnoses of  any intact bitch presenting with malaise or illness, due to the potential for life-threatening disease.

The incide incidence nce of mucome mucometra tra is largel largely y unkno unknown, wn, as the condit condition ion is usuall usually y an incide incidenta ntall finding finding during during ovariohys ovariohystere terectomy ctomy or ultrasound ultrasound examinatio examination n of the reproductive tract. However, 13% of uteri in one study were were found found to have have either either mucome mucometra tra or hydrom hydrometr etraa [25] [25].. 5. Pathogene Pathogenesis sis

Cystic Cyst ic endo endome metr tria iall hype hyperp rpla lasi siaa deve develo lops ps after after repeated repeated progestatio progestational nal stimulati stimulation on during during the luteal luteal phase phase of the estrou estrouss cycle cycle [1] [1].. Althou Although gh CEH is genera generally lly though thoughtt to predis predispos posee the bitch bitch to devel develop op pyome pyometra tra[1,2] [1,2],, the two conditions can develop independently of one another [3] [3].. Furthermore, CEH is also associated with mucometra [7] [7],, as CE CEH H can can res result ult in endo endom metri etrial al thickening with the accumulation of viscid fluid in the uterus. uterus. The main difference difference between between mucometra mucometra and pyometra is that with mucometra the fluid accumulating in the uterus is sterile and with pyometra, it is contaminated with bacteria. During diestrus, a time of progesterone domina dominance nce in the bitch, bitch, proges progester terone one increa increases ses endometrial gland secretory activity, increases endometrial proliferati proliferation, on, decrease decreasess myometrial myometrial contractil contractility ity,, and causes closure of the cervix [7] [7].. These effects are cumulative after repeated estrous cycles, explaining the increa increased sed incide incidence nce in middle middle-ag -aged ed to older older bitche bitches. s. Estrogen stimulation prior to progesterone dominance is also a component of the pathogenesis, although experimental exposure of the endometrium to estrogen alone causes no specific pathologic change [8,26] [8,26].. Suppre Suppress ssion ion of cellu cellular lar immu immunit nity y result resultss from from increa increasi sing ng proges progeste teron ronee conc concent entrat ratio ion n in the early early luteal phase [27] [27].. The combination of reduced local immunity and favorable uterine conditions for pathogens (increas (increased ed glandul glandular ar secreti secretions ons and decrea decreased sed myometrial myometrial activity) activity) make bacterial bacterial colonization colonization more likely during this phase. The most common bacteria Escherichia a coli isol isolat ated ed in case casess of pyom pyomet etra ra is Escherichi [7,25,28] which is also usually found in the feces of  affected affected bitches [29] [29].. Bacteri Bacterial al contam contaminat ination ion of the uterus likely occurs prior to diestrus when the cervix is open, open, and and in case casess of CE CEH, H, the the bacte bacteria ria cannot cannot be cleared prior to the luteal phase, leaving opportunistic organis organisms ms in a prime prime enviro environme nment nt for coloniz colonizati ation on and proliferation. proliferation. E. coli is a particu particular larly ly dangero dangerous us organism in cases of pyometra, due to endotoxin release which may result in septic shock  [30,31] [30,31]..

4. Incidence Incidence 6. Clinical Clinical signs and physical physical exam findings findings

Reported Reported incidences incidences for pyometra pyometra include include 9% [9] and 15.2% [24] [24],, whereas another study found an incidence of 2% in bitches greater than 10 years of age [22] [22]..

Clinical Clinical signs of pyometra in dogs depend primarily on whethe whetherr the the cervi cervix x is pate patent nt enou enough gh to allo allow w drain drainag agee

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of purulent fluid. The most common clinical finding in bitches bitches with open-cer open-cervix vix pyometr pyometraa is a malodor malodorous, ous, sanguinous sanguinous to mucopurulent mucopurulent vaginal discharge discharge [14,17] [14,17].. Bitches with open-cervix pyometra are generally less systemically ill than bitches with closed-cervix pyometra and early in the course of the disease affected affected bitches may show no clinical signs other than vaginal discharge [1,7–9].. Addi [1,7–9] Additi tion onal al clin clinic ical al findi finding ngss may may incl includ udee lethargy lethargy, depression, depression, inappetance/an inappetance/anorexia, orexia, polyuria, polydipsia, vomiting, and diarrhea [12] [12].. In contrast, contrast, bitches with closed-cervix closed-cervix pyometra pyometra are generally very ill at presentation, with marked clinical signs signs of depress depression, ion, letharg lethargy y, polyuria polyuria,, polydip polydipsia, sia, vomiting, vomiting, diarrhea, diarrhea, and possibly possibly abdominal abdominal distension. distension. Affected bitches are often dehydrated and septicemic, toxemic, and in shock. Fever may be present in bitches with pyometra, but those with toxemia toxemia may actually actually be hypothermic [7–9] [7–9].. There is typically no evidence of  vulvar discharge. Pyometra causes varying degrees of systemic illness, but but mu muco come metr traa typi typica call lly y does does not not caus causee obvi obviou ouss clinical signs. Both entities can cause palpable uterine enlarge enlargemen mentt due to fluid fluid accumu accumulati lation. on. In pyomet pyometra, ra, the size of the uterus is inversely inversely proportional to the degree of cervical cervical patency patency [8] [8].. Care should be practiced when palpa palpatin ting g for susp suspec ected ted pyome pyometr traa to avoi avoid d uteri uterine ne rupture. Uncomplicated CEH and mucometra may only cause the outward sign of failure to conceive, due to the abnormal abnormal endometrium endometrium [32] [32].. 7. Diagnosti Diagnosticc findings findings 7.1. Clinical pathology pathology

Cytolo Cytologic gic exami examinat nation ion of vagin vaginal al discha discharge rge is an initi initial al and and very very helpf helpful ul tool tool in diagn diagnos osin ing g cani canine ne pyometra and in differentiating open-cervix pyometra from mucometra. Neutrophils which are often degenerative and present in large numbers are frequently seen on cytolo cytologic gic exami examinat nation ion of vagin vaginal al discha discharge rge with with pyomet pyometra. ra. IntraIntra- and extrac extracell ellula ularr bacter bacteria ia may be seen seen in cytologic cytologic specimens specimens.. With With mucometra, mucometra, cytology may reveal lesser numbers of neutrophils, with or without degenerative changes, red blood cells, endometrial cells (usual (usually ly with with foamy foamy cytopl cytoplasm asm), ), and varyin varying g amounts amounts of  amorphous amorphous debris. With hydrometra, hydrometra, scant red blood cell cellss and and whit whitee bloo blood d cell cells, s, mo mode dera rate te numbe numbers rs of  endome endometri trial al cells cells,, minima minimall mucus mucus and amorph amorphous ous debris debris are evident. With hematometra, red blood cells are the predominant cell type, with scant white blood cells and minimal to moderate mucus, scant endometrial cells and minimal to moderate amorphous debris present.

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A common pathologic clinical finding in bitches with pyometra is a peripheral leukocytosis, which is more pronounced in closed-cervix pyometra [33,34] [33,34].. When When a differ different ential ial cell count count is perform performed, ed, a left shift is also a common findin ding [9,12,15] [9,12,15].. A normocy normocytic tic,, normoch normochrom romic ic anemia anemia may be seen seen in cases of pyometra [7–12] [7–12],, with packed cell volumes ranging from 21 to 48% [10] [10].. Abnormalities Abnormalities in serum chemistry chemistry include azotemia, azotemia, hypergammag hypergammaglobuli lobulinenemia, and hypoalbuminemia [6] [6].. Metabolic acidosis is a common common finding finding [35–37] [35–37].. Urinaly Urinalysis sis finding findingss are less consistent, as dehydration affects urine specific gravity gravity.. Decrea Decreased sed urine urine specifi specificc gravity gravity has been been reported in approximately 20% of cases of pyometra [7].. Specific renal abnormalities have been described [7] in pyometra [7,38] [7,38],, including the decreased decreased ability of  the renal tubules to concentrate urine as a result of  the effects of endotoxin, which accounts for both the decrea decreased sed specifi specificc gravit gravity y and the clinic clinical al signs signs of  polyuria and polydipsia. Proteinuria may be observed [7,39] [7,39].. With With mucome mucometra, tra, the serum serum chemis chemistry try,, leuk leukog ogra ram m and and urin urinal alys ysis is are are typi typica call lly y with withou outt abnormality, except for a possible mild, regenerative anemia. 7.2. Diagnostic Diagnostic imaging

The diagnosis of pyometra is best made with the aid of ultrasonograp ultrasonography hy [40] [40],, and findings findings typically typically include an enlarged uterus with convoluted, tubular horn hornss fille filled d with with anec anecho hoic ic to hypo hypoec echo hoic ic fluid fluid [41,42].. The [41,42] The lumi lumina nall cont conten ents ts are are usual usually ly homo homo-genous, but the contents may also be echodense with slow, slow, swirling swirling patterns patterns [43] [43].. A thicke thickened ned endome endome-trium trium with cystic cystic structu structures res is diagnos diagnostic tic for CEH [41],, with or without pyometra. Endometrial edema [41] may may be prese present. nt. Muco Mucome metra tra or hema hematom tomet etra ra are are suspected if uterine luminal contents are echodence and hydrometra is suspected it luminal contents are anechoic in combination with a lack of clinical signs consistent with pyometra [44] [44].. Radiography may also be used as an aid in diagnosing pyometra in the bitch, but but can can be freq freque uent ntly ly inco inconc nclu lusi sive ve.. The The norm normal al nonpre nonpregnan gnantt and early early pregna pregnant nt uterus uterus are of softsofttiss tissue ue or fluid fluid radio radiopa paci city ty [45–47] [45–47].. Othe Otherr uter uterine ine conditions that have similar soft-tissue radiographic characterist characteristics ics are pyometra, pyometra, mucometra, mucometra, and uterine torsion [45–49] [45–49].. These pathologic conditions of the uterus uterus cannot cannot be differ different entiat iated ed from from early early pregnapregnancy ncy in the bitc bitch h unti untill feta fetall mine mineral raliz izat atio ion n take takess place, which is approximately approximately 45 days after ovulation ovulation [46].. [46]

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8. Conclusi Conclusions ons

Mucometra, hydrometra, and especially pyometra, are disease entities that should be considered a rule out in all intact bitches with the aforementioned clinical signs. Signalment, Signalment, history, history, and physical physical examination examination findings findings are very helpful in diagnosing these conditions. conditions. Differentiatio Differentiation n of mucometra, mucometra, hydrometra, hydrometra, hematomehematometra, and pyometra can be made on the basis of cytologic examination, complete blood count, serum chemistry, urinalysis, and ultrasonography. References [1] Dow C. The cystic endometrial endometrial hyperplasia–pyometra complex in the bitch. Vet Rec 1958;70:1102–8. [2] Sandholm M, Vasenius Vasenius H, Kivisto¨ AK. Pathogenesis of canine pyometra. J Am Vet Med Assoc 1975;167:1006–10. [3] Debosschere H, Ducatelle R, Vermeirsch Vermeirsch H, Van Van Den Broeck W, Coryn M. Cystic endometrial hyperplasia–pyometra complex in the bitch: should the two entities be disconnected. Theriogenology 2001;55:1509–19. [4] Arora N, Sandford Sandford J, Browning Browning GF, GF, Sandy JR, Wright PJ. A model for cystic endometrial hyperplasia/pyometra complex in the bitch. Theriogenology 2006;66:1530–6. [5] Smith FO. Canine pyometra. Theriogenology Theriogenology 2006;66:610–2. [6] Johnston Johnston SD, Kustritz Kustritz MVR, Olson PNS. Disorders Disorders of the canine canine uterus uterus and uterin uterinee tubes tubes (oviduct (oviducts). s). In: Kersey Kersey R, editor editor.. Canine and feline theriogenology. WB Saunders Co.; 2001. p. 206–24. [7] Hardy RM, Osborne CA. Canine Canine pyometra: pathogenesis, pathogenesis, physiology siology,, diagnosis diagnosis and treatment treatment of uterine uterine and extra-ute extra-uterine rine lesions. J Am Anim Hosp Assoc 1974;10:245–68. [8] Dow C. The cystic hyperplasia–pyometra hyperplasia–pyometra complex complex in the bitch. Vet Rec 1957;69:1409–15. [9] Ewald Ewald BH. A survey survey of the cystic cystic hyperplasia–p hyperplasia–pyomet yometra ra complex in the bitch. Small Anim Clin 1961;1:383–6. [10] Stone EA, Littman Littman MP, MP, Robertson JL, Bovee KC. Renal dysfunc functi tion on in dogs dogs with with pyom pyomet etra ra.. J Am Vet Med Med Asso Assocc 1988;193:457–64. [11] Nelson RW, RW, Feldman EC, Stabenfeldt GH. Treatment of canine pyometra and endometritis with prostaglandin F 2a. J Am Vet Med Assoc 1986;189:1557–61. [12] Wheaton LG, Johnson AL, Parker Parker AJ, Kneller SK. Results and and complications of surgical treatment of pyometra: a review of 80 cases. J Am Anim Hosp Assoc 1989;25:563–8. [13] Fidler IJ, Brodey RS, Howson AE, Cohen D. Relationship Relationship of  estrous irregularity, pseudopregnancy, and pregnancy to canine pyometra. J Am Vet Med Assoc 1966;149:1043–6. [14] Renton JP, JP, Boyd JS, Harvey MJA. Observations on the treatment and diagnosis of open pyometra in the bitch (Canis familiaris ). J Reprod Fertil Suppl 1993;47:465–9. [15] Gilbert RO, RO, No¨ thling JO, Oettle´ EE. A retrospective study of 40 cases cases of canine canine pyometrapyometra-metri metritis tis treated treated with prostaglan prostaglandin din F2a and broad-spectrum antibacterial drugs. J Reprod Fertil Suppl 1989;39:225–9. [16] Lundorff Lundorff Jensen A, Bantz M, Dirch Poulsen Poulsen JS. Cystic endometrial hyperplasia/pyometra complex in the dog. Eur Jou of  Comp Anim Prac 1994;4:20–6.

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