a 60-year - old female presented with a history of serosanginous discharge and bleeding ( small amount ) per vaginum for the last 4 months .
she was postmenopausal for the last 10 years with p5 + 1 + 0 + 5 .
local examination revealed hard infiltrative growth destroying both cervical lips and involving the vaginal wall .
the upper third of the lateral and upper half of the anterior and posterior walls of the vagina were involved .
hemogram ( hb  =  11.4  gm% , tlc  =  7600/l ) and renal function tests ( urea  =  24  mg / dl and creatinine  =  0.81  mg / dl ) were normal .
ultrasound of the abdomen and pelvis showed no intra - abdominal / pelvic collection or pyometra . with carcinoma
cervix iii b ( figo clinical staging ) , she was planned for external radiotherapy ( 46gy in 23 fractions over 4.5 weeks ) . but after receiving 18gy/9 fractions , she presented with pain in the abdomen and vomiting .
contrast - enhanced ct showed multiple pelvic and intra - abdominal collections , a dilated endometrial cavity with breach at the uterine fundus and its continuation with large pelvic collection , suggestive of perforated pyometra .
sagittal and coronal reformats in multi - detector ct depicted the site and size of the uterine breach .
the patient was managed with pigtail drainage of the larger pelvic and subhepatic collections , and with appropriate antibiotic cover ( cefoperozone , sulbactam and amikacin ) .
she improved clinically and follow - up ultrasound after 1 week showed near complete resolution of the abscesses , and the catheter was taken out ( fig .
1 and 2 ) . 
 figure 1contrast - enhanced axial ct images showing dilated endometrial cavity with site of the breach at uterine fundus ( arrow ) .
pelvic collections ( * ) are seen with the abdominal / mesenteric extension and resultant intra - abdominal collections ( * ) . 

figure 2contrast - enhanced coronal and sagittal reformatted ct image depicting dilated endometrial cavity with site and size of the breach at uterine fundus ( arrow ) .
contrast - enhanced axial ct images showing dilated endometrial cavity with site of the breach at uterine fundus ( arrow ) . pelvic collections ( * ) are seen with the abdominal / mesenteric extension and resultant intra - abdominal collections ( * ) .
contrast - enhanced coronal and sagittal reformatted ct image depicting dilated endometrial cavity with site and size of the breach at uterine fundus ( arrow ) .
pyometra is an uncommon condition occurring mainly in elderly postmenopausal females , and results when natural drainage of the uterine cavity is compromised .
the common causes of pyometra include malignant condition of the genital tract and sequele of their treatment , benign conditions such as infection and congenital cervical anomalies .
the benign or malignant conditions cause accumulation of secretions and gradual enlargement of the uterus , leading to thinned uterine walls which may be sloughed with spontaneous uterine rupture and causing generalized peritonitis .
spontaneous uterine perforation is rare and extensive review of the english literature has revealed only 26 such reported cases to date .
furthermore , spontaneous rupture of pyometra in cervical cancer presenting as generalized peritonitis is extremely rare and only four cases have been described .
we reviewed all the cases of spontaneous uterine perforation in cervical cancer and the findings are summarized in table 1 . 

no.agesymptomsprovisional diagnosisperforation sitehistologytreatment867ap , gbgpfundussquamous cell carcinomaaspiration and drainage234apgp , ppleft corneal regionsquamous cell carcinomadrainage and pl272apgpfundussquamous cell carcinomadrainage and pl160ap , fgpfundussquamous cell carcinomatah with bsopresent case60ap , f , vgpfundusadeno - carcinomapigtail drainageap , abdominal pain ; bso , bilateral salpingo - oophorectomy ; f , fever ; gb , genital bleeding ; gp , generalized peritonitis ; pl , peritoneal lavage ; pp , perforated pyometra ; tah , total abdominal hysterectomy ; v , vomiting .
cases of spontaneous uterine perforation in cervical cancer ap , abdominal pain ; bso , bilateral salpingo - oophorectomy ; f , fever ; gb , genital bleeding ; gp , generalized peritonitis ; pl , peritoneal lavage ; pp , perforated pyometra ; tah , total abdominal hysterectomy ; v , vomiting .
the most common perforation site was the uterine fundus and in only one case it was the uterine cornual region .
ct features of perforated pyometra have been described in only one case in which ct revealed the diagnosis and surgical intervention was performed . in our case ,
the patient presented with features of generalized peritonitis , ct showed perforated pyometra at the uterine fundus with multiple pelvic and intra - abdominal collections .
sagittal and coronal reformats in multi - detector ct are very helpful in depicting the site and size of uterine breach , demonstrating the resultant intra - abdominal collections and staging of cervical cancer .
the site of uterine breach can be missed on axial images as it is usually seen in fundus ; hence , in elderly postmenopausal females with peritonitis sagittal and coronal reformats of uterus should be carefully evaluated .
sonography plays a limited role in the diagnosis of ruptured pyometra because of its inability to demonstrate the uterine breach and the limited sonographic window available due to perforation .
treatment of ruptured pyometra in cervical cancer patients varies depending on the clinical condition of the patient and the preoperative diagnosis . in most cases drainage of the collections
was carried out , except for one case in which total abdominal hysterectomy and bilateral salpingoophorectomy were peformed .
the index case was managed by putting percutaneous pigtail catheters in pelvic and subhepatic collections .
spontaneous rupture of pyometra in cervical cancer is very rare and should be considered in elderly postmenopausal women with cervical cancer presenting with an acute abdomen .
multi - detector ct with sagittal and coronal reformatted images could play an important role in the diagnosis of ruptured pyometra .
 abstractpyometra is an uncommon condition with an incidence of less than 1% in gynaecologic patients . 
 spontaneous rupture of pyometra in cervical cancer presenting as generalized peritonitis is very rare . 
 only four cases have been described in the english literature to the best of our knowledge and from a pubmed search . 
 the index case is an elderly postmenopausal female who was diagnosed with cervical cancer , started on radiotherapy and presented with features of generalized peritonitis . 
 contrast - enhanced ct revealed uterine perforation at the fundus with multiple abdominal and pelvic collections . 
 a brief review of all the cases of ruptured pyometra in cervical cancer in the literature and a discussion of the role of imaging is presented . 
Case report
Discussion