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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,
particularly closed-cervix pyometra, can be a life-threatening condition that must be recognized, managed, and 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. Introduction 2. Definition

Canine pyometra is a disease of intact bitches that is Pyometra, by definition, is the accumulation of
of particular importance to the veterinary practitioner, purulent material within the uterine lumen of intact
since early recognition, diagnosis and appropriate bitches, typically occurring during or immediately
intervention is required to avoid disastrous conse- following a period of progesterone dominance. Histori-
quences. Closed-cervix pyometra is particularly dan- cally, it has been thought subacute endometritis is
gerous, because septicemia and toxemia may develop followed by cystic endometrial hyperplasia (CEH)
rapidly and left untreated can result in patient death. which then predisposes bitches to develop pyometra
Although mucometra, hematometra, and hydrometra [1,2]. Others suggest that, due to differences in clinical
by themselves are not fatal diseases, they must be and histopathologic findings, CEH and pyometra should
differentiated from pyometra. Several diagnostic aids be classified separately [3]. It is common to see
are available to assist in diagnosing and differentiating pyometra defined as the endometritis/cystic endometrial
pyometra, mucometra, hematometra, and hydrometra. hyperplasia/pyometra complex (CEH/P) [4]. Pyometra
For the purposes of this discussion, the conditions of is classically a disease of the diestrual bitch and can be
hematometra and hydrometra can be used interchange- classified as open-cervix or closed-cervix, with the
ably with mucometra, unless otherwise noted. latter being a medical emergency requiring rapid
intervention to prevent subsequent sepsis and potential
* Tel.: +1 785 263 2301; fax: +1 785 263 2925. patient death [5]. Mucometra, hematometra, or hydro-
E-mail address: [email protected]. metra are thought to occur with CEH, and the character

0093-691X/$ – see front matter # 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.theriogenology.2008.04.028
360 S.D. Pretzer / Theriogenology 70 (2008) 359–363

of the intrauterine fluid differs from pyometra in that The incidence of mucometra is largely unknown, as
they are classically all sterile and are the fluid is the condition is usually an incidental finding during
seromucous, bloody, or serous, respectively [3]. ovariohysterectomy or ultrasound examination of the
reproductive tract. However, 13% of uteri in one study
3. Signalment and history were found to have either mucometra or hydrometra [25].

Pyometra typically affects mature bitches that have 5. Pathogenesis

undergone repeated estrous cycling, with a reported mean
age of 7.25 years [6]. Reported ages for bitches diagnosed Cystic endometrial hyperplasia develops after
with pyometra range from as young as 4 months to as old repeated progestational stimulation during the luteal
as 16 years of age [7–16]. In a group of 192 bitches that phase of the estrous cycle [1]. Although CEH is generally
were treated medically for pyometra, the mean age thought to predispose the bitch to develop pyometra [1,2],
reported was 2.4 years [17]. Historical events of the two conditions can develop independently of one
importance in evaluation of a diestrual, intact bitch for another [3]. Furthermore, CEH is also associated with
pyometra include prior treatment with estrogens or mucometra [7], as CEH can result in endometrial
progestins, whelping history, and date of last estrous thickening with the accumulation of viscid fluid in the
cycle. There appears to be an increased incidence of uterus. The main difference between mucometra and
pyometra in both nulliparous bitches and bitches greater pyometra is that with mucometra the fluid accumulating
than 4 years of age [18]. Prior reviews indicate that in the uterus is sterile and with pyometra, it is contami-
nulliparous bitches comprise approximately 75% of the nated with bacteria. During diestrus, a time of progester-
bitches with pyometra [1,8]. Hormonal therapies that one dominance in the bitch, progesterone increases
include either progestins for estrus suppression or estro- endometrial gland secretory activity, increases endome-
gens for estrus induction or pregnancy termination may trial proliferation, decreases myometrial contractility,
explain the development of pyometra in young bitches and causes closure of the cervix [7]. These effects are
[12,19,20]. Young bitches with anatomic abnormalities of cumulative after repeated estrous cycles, explaining the
the vagina and vestibule, such as strictures and septums, increased incidence in middle-aged to older bitches.
may be predisposed to develop these conditions. Estrogen stimulation prior to progesterone dominance is
Some breeds reported to be predisposed to pyometra also a component of the pathogenesis, although experi-
include the Rottweiler, Saint Bernard, Chow Chow, mental exposure of the endometrium to estrogen alone
Golden Retriever, Miniature Schnauzer, Irish Terrier, causes no specific pathologic change [8,26].
Airedale Terrier, Cavalier King Charles Spaniel, Rough Suppression of cellular immunity results from
Collie, and Bernese Mountain dog [5,21]. Breeds with a increasing progesterone concentration in the early
low risk for pyometra include Drevers, German Shepherd luteal phase [27]. The combination of reduced local
dogs, Daschunds, and Swedish hounds [22]. Other immunity and favorable uterine conditions for patho-
studies have shown no breed disposition [9,12]. gens (increased glandular secretions and decreased
Most bitches present with pyometra within 12 weeks myometrial activity) make bacterial colonization more
after the onset of the previous estrus, with a reported likely during this phase. The most common bacteria
mean of 5.7 weeks. However, pyometra may occur at isolated in cases of pyometra is Escherichia coli
any stage of the estrous cycle or during pregnancy [6]. [7,25,28] which is also usually found in the feces of
Nearly three-fourths of bitches in another study affected bitches [29]. Bacterial contamination of the
presented within 8 weeks of completion of the prior uterus likely occurs prior to diestrus when the cervix is
estrus [23]. No association has been shown between open, and in cases of CEH, the bacteria cannot be
false pregnancy and pyometra [13]. Pyometra should cleared prior to the luteal phase, leaving opportunistic
always be considered in the differential diagnoses of organisms in a prime environment for colonization
any intact bitch presenting with malaise or illness, due and proliferation. E. coli is a particularly dangerous
to the potential for life-threatening disease. organism in cases of pyometra, due to endotoxin release
which may result in septic shock [30,31].
4. Incidence
6. Clinical signs and physical exam findings
Reported incidences for pyometra include 9% [9] and
15.2% [24], whereas another study found an incidence Clinical signs of pyometra in dogs depend primarily
of 2% in bitches greater than 10 years of age [22]. on whether the cervix is patent enough to allow drainage
 S.D. Pretzer / Theriogenology 70 (2008) 359–363 361

of purulent fluid. The most common clinical finding in A common pathologic clinical finding in bitches
bitches with open-cervix pyometra is a malodorous, with pyometra is a peripheral leukocytosis, which is
sanguinous to mucopurulent vaginal discharge [14,17]. more pronounced in closed-cervix pyometra [33,34].
Bitches with open-cervix pyometra are generally less When a differential cell count is performed, a left
systemically ill than bitches with closed-cervix pyome- shift is also a common finding [9,12,15]. A
tra and early in the course of the disease affected bitches normocytic, normochromic anemia may be seen in
may show no clinical signs other than vaginal discharge cases of pyometra [7–12], with packed cell volumes
[1,7–9]. Additional clinical findings may include ranging from 21 to 48% [10]. Abnormalities in serum
lethargy, depression, inappetance/anorexia, polyuria, chemistry include azotemia, hypergammaglobuline-
polydipsia, vomiting, and diarrhea [12]. mia, and hypoalbuminemia [6]. Metabolic acidosis is
In contrast, bitches with closed-cervix pyometra are a common finding [35–37]. Urinalysis findings are
generally very ill at presentation, with marked clinical less consistent, as dehydration affects urine specific
signs of depression, lethargy, polyuria, polydipsia, gravity. Decreased urine specific gravity has been
vomiting, diarrhea, and possibly abdominal distension. reported in approximately 20% of cases of pyometra
Affected bitches are often dehydrated and septicemic, [7]. Specific renal abnormalities have been described
toxemic, and in shock. Fever may be present in bitches in pyometra [7,38], including the decreased ability of
with pyometra, but those with toxemia may actually be the renal tubules to concentrate urine as a result of
hypothermic [7–9]. There is typically no evidence of the effects of endotoxin, which accounts for both the
vulvar discharge. decreased specific gravity and the clinical signs of
Pyometra causes varying degrees of systemic illness, polyuria and polydipsia. Proteinuria may be obser-
but mucometra typically does not cause obvious ved [7,39]. With mucometra, the serum chemistry,
clinical signs. Both entities can cause palpable uterine leukogram and urinalysis are typically without
enlargement due to fluid accumulation. In pyometra, the abnormality, except for a possible mild, regenerative
size of the uterus is inversely proportional to the degree anemia.
of cervical patency [8]. Care should be practiced when
palpating for suspected pyometra to avoid uterine 7.2. Diagnostic imaging
rupture. Uncomplicated CEH and mucometra may only
cause the outward sign of failure to conceive, due to the The diagnosis of pyometra is best made with the
abnormal endometrium [32]. aid of ultrasonography [40], and findings typically
include an enlarged uterus with convoluted, tubular
7. Diagnostic findings horns filled with anechoic to hypoechoic fluid
[41,42]. The luminal contents are usually homo-
7.1. Clinical pathology genous, but the contents may also be echodense with
slow, swirling patterns [43]. A thickened endome-
Cytologic examination of vaginal discharge is an trium with cystic structures is diagnostic for CEH
initial and very helpful tool in diagnosing canine [41], with or without pyometra. Endometrial edema
pyometra and in differentiating open-cervix pyometra may be present. Mucometra or hematometra are
from mucometra. Neutrophils which are often degen- suspected if uterine luminal contents are echodence
erative and present in large numbers are frequently seen and hydrometra is suspected it luminal contents are
on cytologic examination of vaginal discharge with anechoic in combination with a lack of clinical signs
pyometra. Intra- and extracellular bacteria may be seen in consistent with pyometra [44]. Radiography may also
cytologic specimens. With mucometra, cytology may be used as an aid in diagnosing pyometra in the bitch,
reveal lesser numbers of neutrophils, with or without but can be frequently inconclusive. The normal
degenerative changes, red blood cells, endometrial cells nonpregnant and early pregnant uterus are of soft-
(usually with foamy cytoplasm), and varying amounts of tissue or fluid radiopacity [45–47]. Other uterine
amorphous debris. With hydrometra, scant red blood conditions that have similar soft-tissue radiographic
cells and white blood cells, moderate numbers of characteristics are pyometra, mucometra, and uterine
endometrial cells, minimal mucus and amorphous debris torsion [45–49]. These pathologic conditions of the
are evident. With hematometra, red blood cells are the uterus cannot be differentiated from early pregna-
predominant cell type, with scant white blood cells and ncy in the bitch until fetal mineralization takes
minimal to moderate mucus, scant endometrial cells and place, which is approximately 45 days after ovulation
minimal to moderate amorphous debris present. [46].
362 S.D. Pretzer / Theriogenology 70 (2008) 359–363

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