ArticlePDF Available
82
Journal of Current Veterinary Research
ISSN: 2636-4026
http://www.jcvr.journals.ekb.eg Journal homepage:
Pyometra in Cats: Medical Versus Surgical Treatment
Tarik N. Misk1, Taymour M. EL-sherry2
(1) Department of surgery, Anesthesiology & Radiology, Faculty of Veterinary Medicine, Sadat
City University, Sadat City, Egypt.
(2) Department of Theriogenology, Faculty of Veterinary Medicine, Assiut University, Assiut,
Egypt.
*corresponding author: Tarik.misk@vet.usc.edu.eg Received: 25/3/2020 Accepted: 18/4/2020
ABSTRACT
Pyometra is not a common disease in cats however in Egyptian veterinary
clinics where owners do not usually go for elective neutering become a more
common affection. It is an acute or chronic purulent endometritis, a sequel to
progesterone stimulation. The traditional therapy for pyometra is
ovariohysterectomy however medical treatment may be requested by owners or cat
condition may not permit surgical treatment. The aim of the present study is to
characterize the pyometra in cats and compare between ovariohysterectomy and
medical treatment using PGF2α alone or PGF2α in combination with dopamine
agonist. 45 cats were diagnosed with pyometra. Cats divided into 3 groups. Group
1 (n= 23): animals received PGF2α, Group 2 (n= 15): cats received PGF2α plus oral
administration of Bromocriptine. Group 3 (n=7): went for ovariohysterectomy.
Survival analysis of cats was performed in this study for 2 years after diagnosis. In
G1 we censored 14 animals, eight of them returned with recurrent pyometra. The
first recurrent case was recorded 3 months post-treatment. In G2 we censored 12
cats, four of them were returned with recurrent pyometra, the first recurrent case
was met 8 months post-treatment. After 24 months, both G1 and G2 have no
difference in the survival rate which reach for both treatment about 60% success in
both groups. However, G3 survival rate was 100% success. Using dopamine agonist
in medical treatment my delay the recurrences of pyometra for a short term however
ovariohysterectomy whenever possible may be the best choice for treatment of
pyometra.
Keywords: Pyometra, Cat, PGF2α, Dopamine agonist, Ovariohysterectomy.
INTRODUCTION
Pyometra is a common disease in Egyptian
veterinary clinics and countries where cat
owners do not usually go for elective neutering
(Hagman, 2018). It is an acute or chronic
purulent endometritis, a sequel to progesterone
stimulation. Progesterone stimulates the
endometrial gland secretions and decreases the
myometrial contractions which lead to fluid
accumulation, followed by ascending uterine
infection from vaginal bacteria (Hagman et al.,
2014). In cats, it is more likely to occur after
sterile mating (Nelson and Feldman, 1986;
Kenney et al., 1987). The disease is most often
observed in diestrus or as pseudopregnancy,
during progesterone dominance that lasts
approximately 40 days (Hollinshead and
Krekeler, 2016).
In open pyometras, vaginal discharge may be
noticed with mild, nonspecific clinical signs.
However, in closed pyometra, sepsis,
peritonitis, and even animal death may occur
(Hagman, 2018).
The traditional, safest and most efficient
therapy for pyometra is surgical removal of the
genitalia (ovariohysterectomy) (Hollinshead
and Krekeler, 2016). The advantage of
ovariohysterectomy over medical treatment is
that it is curative and preventive for recurrence
of pyometra. However, surgery
Journal of Current Veterinary Research, Volume (2), issue (1), 2020
83
may associate with the risk of anesthesia
specially in senile bad health cats.
During the last decade, numerous medical
treatments have been attempted to treat both
open and closed pyometra (Arnbjerg and
Flagstad, 1985; Davidson et al., 1992a;
Fransson and Ragle, 2003; García Mitacek et
al., 2014). PGF2α has a major effect on the
reproductive tract leads to myometrial
contraction resulting in progressive expulsion
of the uterine contents over a period of days.
Uterine evacuation with PGF2α may be used
only in open cervix pyometra (Amano, 1980;
Arnbjerg and Flagstad, 1985; Davidson et al.,
1992a). Treated cats should be hospitalized
during the day for observation following
prostaglandin administration. Systemic
infection and peritonitis can develop therefore
ovariohysterectomy may be needed. In
addition, many side effects are usually
observed after the injection of PGF2α.
Dopamine agonists can be used for the
treatment of pyometra in cats either alone or in
combination with PGF (Hollinshead and
Krekeler, 2016). Dopamine agonists are ergot-
derived alkaloid compounds that act as
prolactin antagonists and thus have anti-
luteotrophic activity. They are effective from
approximately 1520 days after ovulation when
prolactin is present (erstegen and Onclin,
2006). Therefore, if a queen presents with
pyometra soon after oestrus, anti-prolactinic
agents are preferred over PGF2α as they are
very effective at inducing luteal arrest and
luteolysis in early diestrus (erstegen and
Onclin, 2006) . However, if a queen presents
more than 4 weeks after estrus or mating, use of
a dopamine agonist in combination with PGF2α
potentiates the luteolytic effect, causing more
rapid luteolysis and leading to cervical opening
within 2448 hrs.
There are two commonly used dopamine
agonists: cabergoline and bromocriptine.
Cabergoline is associated with few or no side
effects and involves only once daily
administration, whereas bromocriptine has
several side effects including vomiting,
anorexia, depression, and some behavioral
changes, and also requires administration two
to three times a day. The recommended dose of
cabergoline is 5 µg/kg orally every 24hrs
however, the dose of bromocriptine is 1025
µg/kg orally every 8hrs. Both drugs are
commonly used in combination with PGF,
with the duration of treatment usually being 7
days ( Nak et al., 2009; Hollinshead and
Krekeler, 2016).
The aim of the present study is to characterize
the pyometra in cats and compare between
surgical ovariohysterectomy and medical
treatment using PGF2α alone or PGF2α in
combination with dopamine agonist
(bromocriptine).
MATERIALS AND METHODS
Animals and methods of diagnosis:
In the present study, 45 cats were diagnosed
clinically with pyometra. Seven of these were
cross-breed cats and 38 were Persian. The study
was performed through the period of 2015-
2019. Cases were collected form two private
clinics in Assiut and Giza governorate and at
Assiut veterinary teaching hospital.
Diagnosis of pyometra was confirmed based on
the presence of clinical signs (anorexia,
lethargy, vomiting, abdominal distention, and
vulvar discharge) and ultrasonographical
findings. Trans-abdominal ultrasonography
was performed using a B-mode real-time
ultrasound scanner. A 7.5 MHz linear array
transducer (Mindray 2200, china) &
multifrequency micro convex transducer probe
(Sonoscepe V5, China) were used to confirm
the diagnosis, as well as to monitor possible
recurrence of pyometra from two weeks after
the completion of treatment up to two years
later.
The treatment groups:
The animals were divided into three groups
according to the method of treatment. Group 1
(n= 23): cats received 0.2 mg of PGF2α
(Dinaprost, inj. Lutalyse, Pfizer) I/M with
dexamethasone 0.5 ml I/M and Cefotaxime (as
sodium salt) 250 mg I/M (EIPICO
pharmaceutical, Egypt) for 4 days. Group 2
(n= 15): the same treatment of group1 plus oral
administration of Bromocriptine 0.63 mg
(Dopagone, 2.5 mg/tab, Memphis Co for
pharm, Egypt) for 7 days. Group 3 (n=7)
Ovariohysterectomy with resection of the entire
cervix was performed through a midline
abdominal incision from pubis to midway
between the umbilicus and xyphoid. The uterus
and ovaries were identified, carefully isolated
and excised. The abdominal wall was sutured
routinely using 2/0 absorbable suture material
(Unicryl; Bradid Coated Glycolide
Homopolymer) while skin was sutured using
cross mattress technique with 2/0
polypropylene (Demophoriud Ltd)
Journal of Current Veterinary Research, Volume (2), issue (1), 2020
84
(Hollinshead and Krekeler, 2016). Fluid
therapy was administered despite of the general
health of the patient. Antibiotics were given for
6 days minimum after sensitivity test and
uterine culture. Neck Collars were applied for
at least 7 days after surgery to prevent self-
mutilation. Stitches were removed from twelve
to fourteen days postoperatively.
Survival analysis
Survival analysis of cats was performed
through periodical phone calls every 3 months
for two years after first intervention for any
recurrences. Owners of G1 or G2 who came
back complaining form the retained or
recurrent pyometra, their cats were evaluated
again, diagnosed then subjected to the same
line of treatment. On the other hand, owners
that did not report any recurrences during
periodical calls considered cured while
unreached clients were considered lost data.
Statistical analysis
The size of the uterus monitored by
ultrasonography were compared by one-way
ANOVA while each point was compared using
T-test. The data were represented in mean ±
SEM. Surviving time was considered the period
from the definite diagnosis to the time of
complete recovery or for 24 months post
intervention. Survival rate was analyzed using
Kaplan-Meier curves. All data gathered and
analyzed by using prism 5 software (version
5.01).
RESULTS
The mean age of the cats was 8.20 ±1.06 years
(range 2-13 years).
Clinical signs:
Cat showed signs of anorexia, lethargy,
vomiting and abdominal distention. Vulvar
discharge was obvious in 36 cases while 9 cases
were suffering from closed pyometra. The
duration of signs was between 4 days and 3
weeks. History revealed that two cats were
administered progestins as contraceptive for
heat suppression. Clinically, a distinctive
increase of vulvar discharge was detected in all
cats within the first 24 hrs after application of
treatment in both G1 and G2. All cats were
diagnosed as completely recovered according
to clinic and ultrasonographic findings at 14
days. In all cases, general condition and feed
consumption improved rapidly and were
normal within 7 days of intervention. Vulvar
discharge totally ceased by day 14.
The side effects were found to be rapid
respiration, vocalization with open mouth and
tremor after the PGF2α in G1. While the same
signs in G2 but with vomiting for the first 2
days associated with the oral administration of
Bromocriptine. In G3 there were no signs as in
G1 &G2. Cats regain normal apatite in the 24
hrs following recovery from anesthesia.
Ultrasonography:
During the first ultrasonographic examination
of the cats with pyometra, distended and fluid-
filled uteri were identified cranial and dorsal to
the bladder. Uteri with pyometra appeared as
enlarged with convoluted, tubular horns filled
with anechoic to hypoechoic fluid. The
maximum lumens diameter of the filled uterine
horns was between 0.7 and 5.7 cm at first
examination (figure 1). Then, there is gradual
decrease of pus amount after first PGF2α
administration (figure 2). The results showed
that G2 had a significant decrease in the uterine
amount on day 4 (P<0.05). Uteri could not be
imaged at day 14 in all cats.
Surgical outcomes:
All cats underwent ovariohysterectomy had an
uneventful recovery. In 2 cases, excised ovaries
were associated with follicular cyst and
persistence CL (figure 3) however, excised
distended uterine horns showed yellowish
exudate of pus (figure 4).
Survival rate and recurrences:
Regardless to a short-term success rate of 90%,
the general and reproduction health of cats
followed for 2 years. In G1 (n=23 cats) we
censored 14 animals eight of them returned
with recurrent pyometra. The first recurrent
case occurred 3 months after treatment. In G2
(n=15 cats) we censored 12 cats, four of them
returned with recurrent pyometra (figure 5).
The first recurrent case occurred 8 months after
treatment. After 24 months, both G1 and G2 has
no difference in the survival rate which reach
for both treatment about 60% success of both
groups. However, G3 survival rate was 100%
success.
Journal of Current Veterinary Research, Volume (2), issue (1), 2020
85
Fig. (1): Sonogram showing uteruses with different amount of pus in different cases (a, b and c).
0 4 8
0
1
2
3
4
5G1
G2
*
Days of treatment
Diameter of uterus cm
Fig. (2): Showing the decrease in the diameter of the uterus after evacuation of pus in Group 1 &2. Data represented in
mean± SEM.
Fig. (3): Pyometra after ovariohysterectomy a) Ovarian cyst in an ovary in a cat with pyometra, b) Uterus after
ovariohysterectomy, c) Ovary showing corpus luteum.
Journal of Current Veterinary Research, Volume (2), issue (1), 2020
86
Fig. (4): a) distended uterus filled with pus after ovariohysterectomy of a case suffered from closed pyometra. b) dissecting
of uterus contain pus. c) sonogram showing the anechoic secretion of the pus inside the uterus in a cat with closed pyometra.
0 4 8 12 16 20 24
50
60
70
80
90
100
110 G1
G2
G3
months
Percent survival
Fig. (5): Showing the survival rate of the three groups.
DISCUSSION
The pyometra can be diagnosed at any age. The
disorder has been described as being prevalent
in cats over 5 years of age that have never had
kittens, as well as being most common in cats
that have had one or more litters (Hagman,
2018; Hagman et al., 2014). In our study, the
average age was 8.42 years. Typical clinical
signs are depression, dehydration, lethargy,
pyrexia, anorexia or inappetence, vomiting,
diarrhea, listlessness, abdominal distention,
polyuria and polydipsia and weight loss were
recorded. Only the cats with open pyometra
have an obvious watery or thick and viscous
vulvar discharge. The discharge is often creamy
and light tan-pink to dark brown in color
(Hagman, 2018).
Our results showing that PGF2α in combination
with dexamethasone convert close to open
pyometra and induce uterine contraction. It was
reported that PGF2α induced lutelysis of feline
CL (Hollinshead and Krekeler, 2016) and used
to induce parturition in dogs and cats (Briles
and Evans, 1982). More over PGF also has
ecbolic activity that facilitates drainage of
purulent material from the uterus (Hollinshead
and Krekeler, 2016). Dexamethasone induce
ischemic necrosis of luteal endothelial cells
which lead to ischemic necrosis of luteal tissue
in rats (Gaytán et al., 2002). Both drugs
induced lutelysis and so decrease Progesterone
level which induce cervical relaxation and
increase uterine contractility (Hollinshead and
Krekeler, 2016). In contrary to our results, it
was reported that PGF2α should be restricted to
the open pyometra because of its smooth
muscle contracting effect (Davidson et al.,
1992b).
Many side effects have been observed after
injection of PGF2α within 30 minutes. Cats
begin vocalizing, panting, become restless,
Journal of Current Veterinary Research, Volume (2), issue (1), 2020
87
have tenesmus, salivation, vomiting, diarrhea,
mydriasis, urination, defecation, tail flagging,
and exhibit a lordosis posture. In addition to
intense grooming behavior at the flanks and
vulva.
There are two forms of PGF2 (natural forms
which used in this study; dinaprost and
synthetic form; cloprostenol). It was reported
that Dinaprost has more side effects than
Cloprostenol due to its powerful myometrial
contraction and shorter half-life leading to
faster evacuation of purulent material from the
uterus compared with synthetic prostaglandins
(Verstegen et al., 2008). PGF2α used in
conjunction with antibiotic therapy (Amano,
1980; Hagman et al., 2014; Hagman, 2018;).
Either trimethoprim / sulphadiazine or
amoxycillin trihydrate / clavulanate potassium
is the initial antibiotic of choice (Hollinshead
and Krekeler, 2016).
Cats in G2 showed significant decrease in
diameter of uterus and the amount of pus by day
4 of treatment when compared to G1. It was
reported that dopamine agonists act as prolactin
antagonists has anti-luteotrophic activity
results in rapid reduction in the level of blood
progesterone (Antonov et al., 2015). Dopamine
agonists such as Bromocriptine are
substantially used for the treatment of pyometra
either alone or in combination with PG (Rautela
and Katiyar, 2019). However, bromocriptine
has a number of side effects including
vomiting, anorexia, depression and some
behavioral changes which is recorded in our
results (Hollinshead and Krekeler, 2016).
The results showed that using broad spectrum
antibiotics is effective for reducing the
pyometra in cat. It was recommended that
Antimicrobial therapy should be initiated
immediately with a broad spectrum antibiotic
(Hollinshead and Krekeler, 2016). In our
study, good results obtained with Cefotaxime
injection. It was observed that excellent results
have been achieved with amoxicillin/
clavulanic acid or cephalosporins (Hollinshead
and Krekeler, 2016).
The survival rate showed that the first
recovered case for G1 was 4 months after
treatment while for G2 was 8 months after
treatment. The recovery rate of each group was
the same within 24 months. It was
recommended that all queens intended for
breeding are mated or inseminated on the first
estrus following treatment for pyometra, as a
pregnant queen is significantly less likely to
develop recurrence of pyometra (Hollinshead
and Krekeler, 2016). In our research most cases
were aged and so old aged cats may be
susceptible to return back again.
Surgical treatment for pyometra in cat through
ovariohysterectomy, was a permanent
elimination of the site of infection (Feldman et
al., 2004; Fieni, 2006). If the cat is young or the
owners have the desire to breed from her, or if
she is old and in poor condition for surgical
risk, medical treatment may be attempted (Nak
et al., 2009) otherwise surgical treatment may
be a treatment of choice.
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... Such phenomenon may be attributed to utter disregard of clients in following postoperative guidelines or the inquisitive nature of felines to abuse any sutures tagged onto their skin (Stavisky and Brennan, 2020). This presents a vexing conundrum as neglect may lead to serious self-manipulations of surgical site by veterinary patient (Misk and EL-sherry, 2020). Postoperative seroma has been frequently observed as a common complication after midline incision ovariohysterectomy in domestic cats (Lopez et al., 2020). ...
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The aim of this study was to determine the therapeutic success of the medical treatment of pyometra with the antigestagen aglepristone and to document the recurrence rate in relation to the time interval after treatment with antigestagens in cats. Ten cats, 2-13 years of age and nulliparous were used in the study. The cats were treated with aglepristone at a dose of 10mg/kg body weight subcutaneously on days 1, 2, 7 and 14 (if not cured). In addition, trimethoprim/sulphadoxine was also administered at a dose of 15mg/kg body weight subcutaneously once a day for 7 days. Nine out of the 10 cats responded well to treatment. No recurrence was observed in a follow-up period of 2 years. No side effects were observed. The data suggest that aglepristone treatment is a promising approach for the medical treatment of pyometra in cats.
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Practical relevance Pyometra is a commonly occurring uterine disease in cats that often leads to loss of breeding potential and, in some cases, can be life threatening. An increased incidence of cystic endometrial hyperplasia (CEH) and pyometra is seen with age. Most queens present with uterine lesions after 5–7 years of age (average 7.6 years, range 1–20 years). Clinical signs most commonly occur within 4 weeks of the onset of oestrus in queens that are either mated, spontaneously ovulate or are induced to ovulate (mechanical stimulation or hormone induction). The disease is most often observed in dioestrus. Clinical challenges Queens with pyometra often go undiagnosed as there may be few or only very mild clinical signs and laboratory changes. For example, the classic sign of mucopurulent bloody vulvar discharge often goes unnoticed. Abdominal ultrasound is the best tool for diagnosis of pyometra and for monitoring response to therapy. Patient group Classically, middle-aged/older nulliparous intact queens present with pyometra. However, so-called ‘stump pyometra’ can occur if ovarian tissue is left behind during ovariectomy or ovariohysterectomy (ovarian remnant syndrome). Queens treated with exogenous steroid hormones such as high doses of megestrol acetate or medroxyprogesterone acetate for oestrus prevention can also develop CEH and pyometra. Evidence base There has been little published to date on CEH, endometritis and pyometra in the queen and most of the currently available information has been extrapolated from studies carried out in the bitch. The queen and the bitch have very different reproductive physiology; thus, further research and investigation into the precise aetiopathogenesis of these disease processes of the uterus in the queen is warranted. Audience This review is aimed at clinicians working in small animal practice, especially those in countries where surgical sterilisation is not practised as commonly as in the United States, Canada or Australasia, and who will therefore see a greater proportion of intact queens.
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Sixteen cats affected with pyometra were treated with prostaglandin FF2α (PG) and an antibiotic. A dose of 50-250mu;g of PG was administered 6-22 times, the total dosage of PG being 420-3, 750μg. As a result, the function of the corpus luteun retrograded in 8.8±3.39 days. After that, 12 cats (75%) became pregnant and gave birth to young. One cat given the largest dosage of PG died.
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Treatment with prostaglandin F2 alpha (PGF2 alpha) was evaluated in 21 queens with open-cervix pyometra. The PGF2 alpha was administered (0.1 or 0.25 mg/kg of body weight, sc, q 12 to 24 h) for 3 or 5 days. Transient postinjection reactions caused by PGF2 alpha administration included vocalization, panting, restlessness, grooming, tenesmus, salivation, diarrhea, kneading, mydriasis, emesis, urination, and lordosis. Reactions began as quickly as 30 seconds after PGF2 alpha administration and lasted as long as 60 minutes. All queens improved clinically after PGF2 alpha treatment. One month after completion of the initial series, 1 queen required a second series of PGF2 alpha injections before pyometra resolved. Of 21 queens, 20 (95%) resumed normal estrous cycles without further treatment and 17 (81%) delivered normal litter(s). Use of PGF2 alpha is an acceptable treatment for open-cervix pyometra in queens.