Pyometra

The doctors at the Animal Clinic at Thorndale recommend that all dogs not intended for breeding be spayed or neutered. Please discuss with our doctors the best age for these procedures based on your dog’s breed and size. Spaying will eliminate the possibility of your female dog ever developing a potentially fatal condition called pyometra.

Pyometra is defined as a bacterial infection of the uterus. Unfortunately, most cases of pyometra are much more difficult to manage than a routine infection. The uterus of the dogs is made up of two long horns, extending down from each ovary to join together at a shorter uterine body. The two tubes are designed to spread out a litter of puppies during pregnancy. In a pyometra, the uterine horns fill with pus and blood. An open pyometra occurs when there is drainage from the uterus through the cervix. Owners may see a bloody odorous discharge from the dog’s vulva. In a closed pyometra, the drainage does not occur because the cervical opening is closed. As the pressure continues to build up inside the uterus there is increasing risk of a uterine rupture, spilling the infected contents into the abdominal cavity. In both open and closed pyometra, dogs can become septic (the bacteria spreading throughout the blood stream) and left untreated, death is a likely outcome. Pyometra is an emergency.

Contributing Factors

Pyometra is most often diagnosed within 1-12 weeks after the end of estrus (“heat”). During this time period the dog’s immune capability is somewhat depressed due to the predominance of progesterone hormones in her blood stream. This slight lowering of immunity may be advantageous during a pregnancy to allow the” foreign” puppies take hold in the uterus. Pyometra may be ascending or descending infections. Ascending infections originate through the vaginal vault, through breeding activity, bladder infections, fecal material entering through grooming or diarrhea. Descending infections generally enter through the blood stream and can originate from anywhere else in the body harboring infection. Severe dental disease, open wounds, skin or ear infections, dietary indiscretions all could be potential sources for infectious material to enter the blood stream.

Prevalence

Pyometra is most often seen in middle-aged bitches that have undergone numerous estrous cycles during their lifetime. That said, pyometra can occur after a first heat cycle, as well. There is no known breed predisposition for canine pyometra.

Clinical Signs of Pyometra

Clinical signs depend on whether or not the cervix is open. If it is open, pus will drain from the uterus through the vagina to the outside. It may be noted on the skin or hair under the tail or on bedding and furniture where the dog has been. Fever, lethargy, anorexia (not eating), and depression may or may not be present.

If the cervix is closed, pus that forms is not able to drain to the outside. It collects in the uterus causing distention of the abdomen. The bacteria release toxins that are absorbed into circulation. These dogs often become severely ill very rapidly. They are anorectic, very listless, and very depressed. Vomiting or diarrhea may be present.

Toxins released by the uterine bacteria affect the kidney’s ability to retain fluid. Increased urine production occurs, and the dog drinks an increased amount of water. This occurs in both open- and closed-cervix pyometra.

Any female dog that has not been spayed, showing signs of illness, is suspect for pyometra. This is a very common condition and can be life threatening.

Causes/Transmission

Infection in the lining of the uterus is established as a result of hormonal changes. Following estrus (“heat”), progesterone levels remain elevated for 8-10 weeks and thicken the lining of the uterus in preparation for pregnancy. If pregnancy does not occur for several estrous cycles, the lining continues to increase in thickness until cysts form within it. The thickened, cystic lining secretes fluids that create an ideal environment in which bacteria can grow. Additionally, high progesterone levels inhibit the ability of the muscles in the wall of the uterus to contract. Therefore, any infection occurring cannot be readily expelled.

Other Causes of Pyometra

The use of progesterone-based drugs can cause pyometra. In addition, estrogen will increase the effects of progesterone on the uterus. Drugs containing both hormones are occasionally used to treat certain conditions of the reproductive system or urinary incontinence.

Entry of Bacteria into the Reproductive Tract.

The cervix is the gateway to the uterus. It remains tightly closed except during estrus. When it is open, bacteria that are normally found in the vagina can enter the uterus rather easily. If the uterus is normal, the environment is not well suited to bacterial survival; however, when the uterine wall is thickened and cystic, perfect conditions exist for bacterial growth. In addition, when these abnormal conditions exist, the muscles of the uterus cannot contract properly. This means that bacteria that enter the uterus cannot be expelled. The most common bacterium isolated is E. coli.

Diagnosis

Dogs that are seen early in the disease may have a slight vaginal discharge and show no other signs of illness. However, most dogs with pyometra are not seen until later in the illness. Any very ill female dog that is drinking an increased amount of water and has not been spayed is always suspected of having pyometra. This is especially true if there is a vaginal discharge or an enlarged abdomen.

Dogs with advanced pyometra have a marked elevation of the white blood cell count and often have an elevation of globulins (a type of protein produced by the immune system) in the blood. The urine may be very dilute due to the toxic effects of the bacteria on the kidneys. However, all of these abnormalities may be present in any dog with a major bacterial infection.

Especially if the cervix is closed, radiographs (x-rays) of the abdomen will often identify the enlarged uterus. If the cervix is open, there will often be such minimal uterine enlargement that the radiograph may not be conclusive. An ultrasound examination can also be helpful in identifying an enlarged uterus and differentiating that from a normal pregnancy.

A complete blood count and chemistry and urinalysis are helpful to demonstrate the elevated white cell and globulin levels, kidney function, potential organ failures due to septicemia.

Treatment

The preferred treatment is to surgically remove the uterus and ovaries. This is called an ovariohysterectomy (“spay”). Dogs diagnosed in the early stage of the disease are very good surgical candidates. The surgery is slightly more complicated than a routine spay. Care must be taken handling the diseased tissues and the reproductive tract can be greatly enlarged and friable. Most dogs are diagnosed when they are quite ill so the surgery is not as routine as the same surgery in a healthy dog. Intravenous fluids are needed before and after surgery. Antibiotics are given for 1-2 weeks. If the uterus has ruptured or ruptures during surgery, the risks to the dog’s survival increase dramatically. If the dog is septic going into surgery, there is risk of organ failure and heart problems during and after the surgery.

Because there are severe complications possible, immediate diagnosis and treatment are needed.

Alternative Therapy

Occasionally a valuable breeding dog will be presented with a pyometra. Most veterinarians will still recommend surgical treatment (ovariohysterectomy or spay). After careful discussion with the owner and acceptance of risks, including possible death of the dog, there is a medical approach to treating pyometra. Prostaglandins are a group of hormones that reduce the blood level of progesterone, relax and open the cervix, and contract the uterus to expel bacteria and pus. They can be used successfully to treat this disease, but they are not always successful, and they have some important limitations.

1. They cause side effects of restlessness, panting, vomiting, defecation, salivation, and abdominal pain. The side effects occur within about 15 minutes of an injection and last for a few hours. They become progressively milder with each successive treatment.
2. There is no clinical improvement for about 48 hours so dogs that are severely ill are poor candidates. Emergency ovariohysterectomy is the only reasonable options for these dogs.
3. Because they contract the uterus, it is possible for the uterus to rupture and spill infection into the abdominal cavity. This is most likely to happen when the cervix is closed.

There are some important statistics that you should know about this form of treatment:

1. The success rate for treating open-cervix pyometra is 75-90%.
2. The success rate for treating closed-cervix pyometra is 25-40%.
3. The rate of recurrence of the disease is 50-75%.
4. The chances of subsequent successful breeding is 50-75%.

Because most veterinary hospitals do not keep these prostaglandins in stock, there is often a delay in procuring them and being able to treat. In many cases the dog’s health will continue to deteriorate, making the success of treatment, either medically or surgically, less likely.

Antibiotics are warranted in all cases of pyometra.

Prognosis

The possibility of successfully resolving pyometra without surgery or prostaglandin treatment is extremely low. If a treatment is not selected and performed quickly, the toxic effects from the bacteria will be fatal. If the cervix is closed, it is also possible for the uterus to rupture, spilling the infection into the abdominal cavity. This will also be fatal. Pyometra is a true emergency. In all but a few select cases, surgical removal of the ovaries and uterus are required to successfully treat these often very ill patients. Prompt recognition by an owner can be life saving.