Case notes

A 78-year-old woman came to the emergency department febrile with pelvic pressure and urinary retention. Past surgeries included a total colpocleisis 2 years earlier for pelvic organ prolapse and a remote history of a total abdominal hysterectomy. Her abdomen was nontender; the introitus was surgically obliterated, and a rectal examination confirmed a large pelvic mass. A computed tomography scan revealed a large, heterogeneous, predominantly low-density collection in the pelvis with multiple enhancing septations and a thick external rind ( Figures 1 and 2 ). With persistent fever despite antibiotics and concern for malignancy, the patient underwent surgical exploration that revealed an enlarged, hardened mass at the vaginal cuff, with adherent bladder and sigmoid colon. Retrograde bladder distention and placement of an end-to-end anastomosis sizer in the rectum aided tissue plane identification. The vaginal cuff was opened and was drained of purulent fluid, which ultimately grew Streptococcus a nginosus . The patient’s postoperative course was uncomplicated.

Axial computed tomography scan

View of pelvic mass, markers A and B are used to outline the width and depth.

McCluskey. Pyocolpos after total colpocleisis. Am J Obstet Gynecol 2015 .

Coronal computed tomography scan

View of large heterogeneous collection in the pelvis. The vertical marker has been used to show the vertical length.

McCluskey. Pyocolpos after total colpocleisis. Am J Obstet Gynecol 2015 .

Conclusions

Colpocleisis is an effective obliterative procedure for advanced pelvic organ prolapse with minimal morbidity. Pyometra has been reported after a partial (Le Fort) colpocleisis that likely resulted from inadequate lateral vaginal drainage channels. Pyocolpos is associated most commonly with congenital anomalies of the female genitourinary tract when abnormal or incomplete vaginal canalization leads to retention of secondarily infected secretions. Rare postmenopausal cases have been attributed to underlying infection, trauma, or neoplasm. We identified no cases of pyocolpos in association with colpocleisis when we searched for the terms pyocolpos and colpocleisis in PubMed. We hypothesize that the obliterated vaginal vault became secondarily infected by a relatively indolent bacteria that led to slowly progressive inflammation and abscess formation. The clinical presentation closely mimicked an intraperitoneal abscess or secondarily infected neoplasm. Although a detailed summary of the patient’s colpolcleisis was not available, vaginal epithelium deep to the closure, choice of suture material, presence of vaginal ulcerations, or postoperative infection potentially could predispose to the problem that we encountered.

In conclusion, pyocolpos should be considered in patients with a history of an obliterative vaginal procedure who have an abdominopelvic mass. Recognition of this pathologic condition should lead to prompt and potentially less invasive intervention with a vulvovaginal approach.