Veterinary Quarterly

ISSN: 0165-2176 (Print) 1875-5941 (Online) Journal homepage: http://www.tandfonline.com/loi/tveq20

Cystic endometrial hyperplasiapyometra complex

in cats. A review
C.F. Agudelo
To cite this article: C.F. Agudelo (2005) Cystic endometrial hyperplasiapyometra complex in
cats. A review, Veterinary Quarterly, 27:4, 173-182, DOI: 10.1080/01652176.2002.9695198
To link to this article: http://dx.doi.org/10.1080/01652176.2002.9695198

Published online: 22 Jun 2012.

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Date: 14 February 2016, At: 18:58

173

Veterinary Quarterly 2005; 27(4): 173-182

Cystic endometrial hyperplasia-pyometra complex in cats.

A review
C.F. Agudelo*
Department of Internal Medicine, Clinic of Dog and Cat Diseases, Faculty of
Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences Brno,
Czech Republic

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TABLE OF CONTENTS

Summary and keywords

174

Short description

174

Etiopathogenesis and epidemiology

174

Clinical signs

176

Diagnosis

177

Treatment

178

Ovariohysterectomy

179

Medical treatment

179

Conclusions

181

References

181

*Address: Clinic of Dog and Cat Diseases, Faculty of Veterinary Medicine,

University of Veterinary and Pharmaceutical Sciences,
Palackho 1/3, Brno, Czech Republic
E-mail: cagudelo@vftc.cz

174

Cystic endometrial hyperplasia-pyometra complex in cats.

A review
C.F. Agudelo
SUMMARY

Presentation of complex cystic endometrial hyperplasia-pyometra is not very common in cats. As in

bitches, hormonal influences result in environmental and histological changes in the uterus leading to
predisposition to bacterial growth. Its influence on the organism provokes certain clinical signs.
Diagnosis and treatment must be fast and aggressive. Depending on the clinical status and queen
purpose, it can be both surgical or medical. Both of them offer a high rate of success if the detailed
protocols are followed.

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Keywords: Cat diseases; CEH; Corpora lutea; Cystic endometrial hyperplasia-pyometra complex; Endometritis; Ovariohysterectomy; Progestagens; Prostaglandins; Pyometra; Queen; Uterine diseases.

Short description
Cystic endometrial hyperplasia-pyometra is a
disease, which is mainly characterized by
progesterone-induced hyperplasia of the endometriurn with cystic dilatation of the endometrial glands

and inflammation of the uterus with purulent content in the uterine lumen leading to several clinical
signs (2,5,20,33, 34).

Etiopathogenesis and epidemiology

It is important to realize that the queen is a species

follicular cycles (9). Estrous returns whithin 14-19

days after a non-ovulatory cycle (17).
The hormone progesterone causes, a)hyperplasia of
the endometrium, especially of the superficial
epithelium and the endometrial glands (17),
b)
closure of the uterine cervix(27), increase of the
secretory activity of the endometrial glands (2,10,
20,27,33,34,37,40), and decrease of myometrial
contractibility, although it can be hyperplastic
(17). Intrauterine leukocytary response suppression
to foreign stimulus has been reported (5,40). The

with induced ovulation, which requires coitus or

mechanical stimulus of the cervix or the vagina to
liberate luteinizing hormone (LH) and subsequent
ovulation (11,12,17,18,19,40). Coitus as an

first phase of the illness is the proliferation and

cystic dilation of the glandular endometrium with

trigger stimulates the release of

gonadotropin releasing hormone (GnRH) from the

hormonal stimuli, and is denominated cystic

endometrial hyperplasia (CEH) (17,20,22,27).
Changes in the uterine microenvironment and
decreased contractibility would favor ascendant
bacterial infection (2). During pseudopregnancy,

external

hypothalamus. GnRH stimulates release of LH

from the

anterior hypophyseal

gland

in the

subsequent minutes with a peak 4 hours. later.

Ovulation occurs 30 to 50 hours after coitus
(17,29). It has been observed that the increase of
the number of copulations accounts for higher
magnitude and longer duration of liberation of LH
with higher ovulation probability when compared

with one mating only (14,15,19,28,31). Corpora

lutea start to produce progesterone 24-48 hours
after ovulation (17). When this happens, this phase
corresponds to the pregnancy or pseudopregnancy
(when the queen is not pregnant). This phase

comes to an end after 40-50 days (9,10,14,17).

The whole period of progesterone influence over
uterus is shorter when compared to the bitch (over
60 days) (10,40). Queens are not affected by
progesterone influence between non-ovulatory

fluid accumulation in the uterine lumen. The

ocurrence of this phase is influenced by age and

the changes induced by the progesterone on the

glandular epithelium begin to disappear after 4
weeks, while during pregnancy endometrial
morphology and synthetic activity continues
simultaneously with the pregnancy (12).

However, these findings are not consistent; recent

information shows that queens can have spontane
ous ovulation after a non fertile breeding (16,17,
18,19,40) or after pharmacological treatments (4,
12,27,39). It has been observed that some queens
were in luteal phase, though they were separated

from males and have not received any therapy.

This suggests that the luteal phase can be induced
by diverse factors (2,14,16,29) (visual, tactile, etc.
[33,17]).

175

It has been noticed that progesterone is not the

only hormonal factor involved in the process.
Some queens have been diagnosed with pyometra

in follicular phase of the ovarian cycle (36,40).

This can be due to the non-gestate uterus

in

diestrus that is flaccid and contains some endometrial gland secretions that were developed previ-

ously as a response to the risen estrogen level in

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time of the estrous (5,40). Recent information

shows that pyometra is not only influenced by
progesterone but also estrogens (29,40). Estrogens
a)increase progesterone receptors in the endometriurn, dilate uterine cervix, allowing bacterial
ascent that is part of the normal vaginal flora and
c)can influence endometrial changes. These endometrial changes are influenced by chronic estrogenic stimulation from recurrent estrous cycles,
which do not end in pregnancy (5,17,20). This all
explains why cystic endometrial hyperplasia (CEH)
was not experimentally induced with any hormonal
treatment (29).

has been observed between pyometra and corpora

lutea presence (2). In about 40-70% of the cases
corpora lutea were present (13).
In most cases of of CEH-pyometra complex
bacterial infection originates from the normal

opportunistic flora of the vagina. The abnormal

endometrium can be a predisposing factor to the
bacterial

colonization

(2,12,21,33,40). Less
frequently bacterial infection is of haematogenous
origin (5). Pyometra can be a type of CEH
associated with predominance of inflammatory
cells inside the uterine lumen and secondary
bacterial infection (12,17). Pyometra and CEH
frequently coexist, although both abnormalities can

represent a single pathological process. A certain

grade of CEH is

found

in every queen with

pyometra, except for a number of cases of pyometra with closed cervix, because in these cases there
is already endometrial atrophy (12).
Aerobic bacteria are recovered from approximately

80% of the animals (39). Escherichia coli is the

CEH is a common histological finding in nulliparous queens older than 3 years and in other queens

most frequently isolated microorganism from feline pyometras (5,11,12,14,16,17,18,19,20,33). The

older than 5 years with no relationship to the

role of bacteria in the pathogenesis of the CEHpyometra complex is especially important in the

number of parturitions (10,12,29,36), although it

has been mentioned that these proportions are very

luteal phase. Isolated bacterial strains from patients

similar (8,10). Pyometra has been observed in

with pyometra can be biochemically simi-lar to

queens older than 8 years and in younger queens

7 years

their faecal homologous suggesting faecal contamination of the genitourinary tract (2). Other agents
like Streptococcus, Staphylococcus, Klebsiella,

(2,14). Elderly nulliparous queens would be more

likely to develop the disease due to the endometrial
changes above discussed (13,17,28). Some patients
have experienced estrous 8 weeks prior to diagnosis and in many cases it is not known whether
there was mating (2,12,40). There is no correlation between the development of the disease, the
age of the first mating or parturition and number
of litters delivered. On the other hand, correlation

Pseudomona, Proteus, Moraxella and Pasteurella

have also been reported (10,12,29,33,34). Mycoplasma, although it has not been proven in cats
should also be suspected (14,30). Uterine tuberculosis and brucellosis acquired from infected bovine
tissues have also been reported in the cat (14).
A CEH classification has been established in cats
according to the clinical, paraclinical and histopathological criteria (7,13,33) (Table 1).

after

progestagen

administration

(20,21).

average age of cats with pyometra

is

The

Type of CEH

Short description of the characteristics

Type I

CEH without inflammatory process, no clinical signs.

Type II

CEH with acute endometritis. In most cases presence of corpora lutea. White Blood Count (WBC) increase.
Signs can vary depending on the severity of the endometrial reaction and distention of the uterus, but in
general the cats are ill.

Type III

Subacute endometritis with mononuclear infiltration of the endometrium and cystic changes of the endometrial
glands. The clinical signs are more pronounced than in the the preceding types. Important WBC increase.

Type IV

Chronic endometritis with endometrial atrophy. The severity of the clinical signs depends among others on the
WBC, the abdominal distention and damage in other abdominal organs.

Table I. CEH classification according to Dow (7).

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176

Use of exogen progesterone in queens with contraceptive purpose can also induce pyometra, especially in young queens (5,20), even in ovariectomized queens (14). However, when this application
is controlled, only over long periods CEH effects
and sterility can been seen with consequent development of pyometra (22). Another study demonstrated that weekly administration of 2 mg chlor-

interrupt gestation can result in pyometra in cats

older than 4 years, because the uterine cervix stays
open longer (20). Doses are reviewed elsewhere in

madinone acetate caused pyometra in two out of

24 treated queens, in connection with mammary
abnormalities (35). Use of exogenous estrogens to

were presumed to have similar effects on fertility

(5,22). The severity of endometrial hyperplasia

the literature (22,27,35).

Adenomatous hyperplasia and cystic changes were

combined to determine the overall cumulative
increase

in

endometrial

thickness

(endometrial

hyperplasia index) in wild cats. These changes

was categorized (Table 2).

Endometrial hyperplasia index

Histopathological features

Grade 0

No hyperplastic changes.

Grade 1

Minimal to mild proliferative and/or cystic changes in glands or surface epithelium without
an increase in overall endometrial height.

Grade 2

Moderate hyperplastic and/or cystic change with an increased endometrial thickness of <2
times normal.

Grade 3

Severe hyperplastic and/or cystic changes with increased endometrial thickness of

<2 times

normal.

Table 2. Endometrial hyperplasia index according to Munson et al. (22).

This study clearly demonstrated a correlation

between contraception using synthetic progesterone
(megestrol acetate) and the development of

queens with the above mentioned infection had

advanced endometrial hyperplasia, which seems to

be irreversible. These results clearly suggest not to

repor-ted in bitches. This happens because of

administration of progestragens to castrated

use these kinds of drugs in reproductively and

queens, which still have uterine remnant (10,14).

Pyometra can also be present in masculine uterus

genetically valuable animals (22).

pyometra (33).

Stump pyometra can be produced similar to that

In recent studies, a functional classification of the

pathologic complex is based on the ovarian phase
(12,17,40). In these studies, queens with
inflammatory uterine disease or infertility with
active corpora lutea showed CEH, myometrial
hyperplasia and increased progesterone . levels
(1,87 ng/ml), while queens with follicular ovaries

and hermaphrodites (2,32).

did not display these changes and had very low

progesterone levels (0,15 ng/ml) (16). However,
normal ovaries, which are not in luteal phase or
with cystic follicules are found in approximately

embryonic death (17). In the case of marked CEH,

abdominal distention can be observed because of

15-23% of the queens with pyometra (12).

Endometrial changes induced by progesterone not

necessarily disappear after involution of the
corpora lutea.
Queens with
infection that

Feline

Infectious

are or have been

(FIV)
pregnant, can

Virus

succumb to complicati-ons of reproductive type

(abortion, stillbirth, etc.), in various time after

mating. One study described that 3 out of 13

Clinical signs.
Cats with CEH not always show clinical signs, but

can be associated with implant failure and

subsequent smaller littermates and also infertility
(secondary anestrous) (10,12,28) as well as early
it

accumulation in the uterus (mucometra,

hydrometra) (12,40).
Pyometra and other forms of uterine inflammation
fluid

almost always cause clinical signs (12). The most

common clinical finding is vaginal mucopurulent
to hemorrhagic discharge (2,5,8,10,12,15,17,33)
occurring in about 75% of the cases (20).
However, this symptom can also be absent due to
careful cleaning habits of the queens (21,34,40) or
in cases of a closed-cervix pyometra (5). Uterus
can be palpated as a big sized mass and there can
or cannot be abdominal distention (8,12,15,20). In

177

closed-cervix pyometra the latter is common (10,

21). This finding is more evident in queens than in
bitches (34). In those cases, patients are more
prone to endotoxemia and uterine rupture with
concurrent peritonitis (2,5,17,20). This is the
reason for the need of being careful when carrying
out abdominal palpation to avoid iatrogenic rupture
(29). Non-specific clinical signs such as anorexia,

vomiting, lethargy, loss of weight and unkempt

appearance can also be observed (2,10,12,14,15,
29).

Polyuria and polydypsia do not occur as often as

in dogs. They were reported only in 9% of the

cases

(2,12). As

reported in dogs,

E.

coli

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endotoxins interfere with Na+ and Cl absortion in

the loop of Hen le, thereby reducing medullary
hypertonicity and resulting in impaired water

absorption. Additionally E. coli endotoxins block

antidiuretic hormone on the
collecting ducts, leading to obligatory polyuria
with compensatory polydypsia (21).
In almost one third of the cases severe dehydration
is identifiable at the moment of the clinical
receptors

for

examination, partly due to the advanced stage of

the disease (2,33). Similarly as reported in dogs,
20-25% of the cases show fever (12,20). In cases
with shock signs (tachycardia, tachypnea and poor
peripheral perfusion) hypothermia can be found
(25).

Stump pyometra must be suspected in a castrated

queen

with

purulent

or

hemorrhagic

vulvar

secretion, being more complicated in cases with

closed-cervix pyometra (9,14).

The most important differential diagnosis for these

historical and physical findings is pregnancy with
concurrent disease (2,12,20), diseases that produce
vaginal discharge such as urinary, uterine and
vaginal diseases (25), diseases that cause increase

of the uterine content (mucometra, hydrometra,

haemometra) and diseases with concurrent abdominal distention (ascites, obesity, abdominal masses,
congenital disorders, peritonitis) (24,33,35).

Diagnosis
The diagnosis is based on the history, the estrous
cycle status and the clinical signs (estrous dates,
hormonal treatments, antecedent of irregular
cycling, and pseudopregnancy) (5,12,33).

Animals with CEH have normal blood and urine

tests (8). Haematology can show non regenerative
normocytic normochromic anaemia due to the

chronic inflammation and toxic effects that cause

suppression of the erythropoiesis in the bone

marrow (12,20,33). Other causes can be diapedesis
of erythrocytes towards the uterus because of the
inflammatory process, blood loss during surgery
(if it is the treatment of choice) and haemodilution
due to fluid therapy (34,41).

Most of the queens with pyometra show abnormal

white blood counts frequently characterized by

leukocytosis with neutrophilia and left deviation
with values than can oscillate from 20.000 up to
120.000/m1 (12,10,33,23), in approximately 66%
(14). Leukopenia can be present in around 5% of
the cases (2,12).
Vaginoscopy

is

also

recommended

for direct

observation of the haemorrhgaic or mucopurulent

discharge (9) originating from the uterus, primary
or secondary hyperaemia, inflammation of the
cervix and vagina or any other pathologic process.
At the same time it is recommended to perform
cytology of the secretions to support the diagnosis.

The most common finding is the evidence of

abundant neutrophils blended with erythrocytes.
Leukocytes can show different states of karyorrhe-

xis and karyolysis (2,33). Endometrial cells can

also be found (2). Presence of bacteria is quite
rare, however this finding must be correlated with
culture and antibiogram to establish a proper treatment (12,41). Samples can be taken directly from
uterine lumen after ovariohysterectomy (OVH) or
from secretions from the cranial vagina if an
immediate sample is required or the medical
management has been chosen (2).

The biochemical profile usually does not show

huge abnormalities. Hyperglobulinaemia can be
present in 30-60% of the cases (2,5,12). In cases
of sepsis and shock, it is also possible to find
hypoglycaemia due to increase of the consumption

of glucose, rapid glycogen storage waste and

decrease in gluconeogenesis

(3,41). Additional
non-specific manifestations like hypokalaemia and
azotaemia are generally due to hypovolaemia and
circulatory collapse. Hyperbilirrubinaemia and
increase of activity of the alkaline phosphatase are
found in about 12% of the cases, and are probably

due to a hepatic perfusion decrease or toxicity,

secondary to sepsis (12,20). However, most of the
cases are self-limited and are solved after starting
the supportive treatment (12,41). Hyperproteinaemia and hyperfibrinogaenemia can be found due to
dehydration or inflammatory process.

178

Reported findings in the urinalysis are proteinuria

and isostenuria (20). Urine collection must be carried out carefully because of the high probability

infection due to catheterization. To avoid uterine

viability must be performed. Ascitic fluid

suggesting possible uterine rupture, can be
identified in a small percentage of cats with
pyometra (13).

perforation, cystocentesis should be performed

only by ultrasound guided technique (2).

Treatment

of sample contamination or favor urinary tract

In most of the cases blood progesterone levels are

increased (>5 ng/ml) because of corpora lutea

activity, although it has been reported that it is
possible that the plasma progesterone is not

required to induce or to maintain pyometra. In

other words it is possible to find normal levels
(4,9).

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(5). Furthermore, if pregnancy is detected, fetal

Radiology of the abdomen can confirm the uterine

enlargement: the x-rays will identify an uterus that

emerges from the pelvis as dilated, showing a

homogeneous and sometimes sacculiform structure
with dorsal and cranial displacement of the small
intestine (1,12,6,26,33,23,36). Cases of closed-

cervix pyometra cases with pregnancy of the

contralateral horn can be detected by x-rays (33).
In earlier pregnancy, ultrasound is always recommended because the radiographic appearance of
pyometra and the gravid uterus are essentially
identical until fetal calcification is detectable in
approximately 40 days' gestation (5,12,13). Care
must be taken with organ overimposition that can
confuse diagnosis (i.e. urinary bladder) or in the
cases of slight pyometra that can be more difficult
to detect (23).
.

Pneumoperitoneum certainly improves radiograph

quality, but any procedure that involves abdominal
manipulation (punction) should be avoided due to

the risk of perforation of distended uterus with

weakened walls (33).

In most cases ultrasound is preferred because in

this way pregnancy can be easily differentiated
from a big uterus filled with anechoic or hypoechoic fluid (5,6,9,10,12,26,36,42) with a contou-

Treatment should be rapid and aggressive, because

septicaemia and endotoxaemia can develop at any
time (2,12,13). When pyometra is suspected, a
detailed and careful clinical examination is needed.
Similar as in dogs, pyometra in cats is considered
as an emergency (41). Treatment includes correction of fluid deficits, proper administration of
antibiotics against bacterial organisms and removal

of infected uterine contents. The latter can be

achieved surgically by OVH or medically by
PGF2c, (10,12).

No matter which option is choosen, medical or

.

surgical,

fluid therapy should be accurate to

replace deficits (acid base and electrolytic, mainly

potassium), correct azotaemia and maintain adequate tissue perfusion. In most cases, it is recommended to administer glucose endovenously, even

in the post-operative period so that the risk of

hypoglycaemia is minimized. Such situation is

very common in the sick cat. Antibiotics should be

choosen according to the culture sensitivity (2,12,
20).

While waiting for the results of the tests of the

antibiotic

sensitivity,

wide

broad

bactericide

antibiotics against the most common bacteria (E.

coli)

is

recommended

(2,12).

This

includes

ampicillin (20 mg/kg IV, IM, SC or PO, TID),

trimethoprim sulfonamide (15-30 mg/kg PO, SC
or IV, BID), clavulanate + amoxicillin (20-25
mg/kg PO, SC, IM or IV, TID), enrofloxacin (5
mg/kg IM or SC, SID) and cephalosporins (i.e.
cephalexin, 20-40 mg/kg, PO, TID or cephalotin,
15-25 mg/kg IV, IM or SC, TID) (2,12,13,17).
The

use

of

other

antibiotics

(tetracyclines,

red or straight shape containing small liquid

chloramphenicol and aminoglycosides) are also

accumulations (<5mm) in the walls. Pregnancy in

cats can be detected ultrasonographically after 21
day in cats (8). Sometimes it is possible to identify
"spotted" echogenicity with multiple cysts from 1

efficient in the treatment of E. coli, but they are

poorly tolerated by some cats (39). E. coli can be
resistant to ampiciline, cephalotine and tetracyclines. Enrofloxacin other fluorquinolones can reach

to 5 mm in the uterus. These can be thickened

necrotic tissue accumulation or wall enlargement
(5,17). Differentiation should be made between

higher therapeutic levels in the uterus as well as in

other fluorquinolones (2).
The decision to try medical or surgical therapy is
based on the physical status and breeding capacity

uterine horns and intestinal loops, although

it

of the queen. The surgical approach should be

would result in a very different symptomatology

considered if a critical or unstable situation exists

endometrium,

small

mucous,

hemorrhagic

or

179

due to septicaemia, shock, azotaemia, if there are

radiographic evidence of uterine rupture or peritonitis or mummified fetal remaining, because the
removal of the infected material becomes necessary. Medical treatments to empty the uterus can last
several days and thus complicate the situation and
the pharmacologic effects can be deleterious for a
patient

severely

affected

and

must

only

be

performed in those queens with minimal systemic

compromise and high reproduction value (9).
Systemic antibiotic therapy alone or combined with
vaginal antiseptic showers, is not effective in
solving the clinical problems (5,8,17).

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Ovariohysterectomy
This surgical therapy has been considered to be the
treatment of choice as it is curative per se (5,9,12,
13,17,28,33,37). However, despite its safety, it
has been associated with mortality and morbidity
rates despite its safety, sepsis being the most
common cause of death rather than surgical techniques or anaesthetic protocols. Surgical techniques
and anaesthesia should be carried out very carefully to minimize the mortality and morbility. It has

been demonstrated in dogs that the inability to

diminish azotaemia prior to surgery has been
associated with higher mortality. This rate has

they are concerned (10). However, in some references it is mentioned that this is not useful and
must be avoided in geriatric patients older than 8
years (9). It is important to rule out fetal presence
before treatment, because of the drug's abortive
effects: PGF2a can cause abortion in queens up to
the 40th day of pregnancy due to myometrial contraction and fetal expulsion. In advanced pregnacy
this would not need to happen because of the concurrent placentary progesterone production. On the
other hand, one author claims that this production
only occurs after the 45th day (5).

Mechanisms of action of PGF2a include uterine

contractions (myoepitheliurn contractions), opening
of the cervix and functional arrest of corpora lutea
or even luteolysis (5,33, 39,40). The sensitivity of
corpora lutea to the prostaglandin effects depends

on the age of the corpora lutea, the dosage of

prostaglandin, and the duration of treat-ment (13).
This response is idiosyncratic in every individual
queen. When administered early in diestrus,

PGF2a is not luteolytic in the queen (14). After

PGF2a

administration,

concentration decreases.

plasma progesterone
This is attributed to

luteolysis or esteroidogenesis inhibition through

the exhaustion of free intracellu-lar cholesterol and
this effect is

been calculated in 5 to 8% of the cases (2,12,14).

Lethargy, vomiting, fever and postoperative anorexia are the most common postoperative morbidi-

more pronounced when diestrus

finishes. In queens, therapeutic dosage of PGF2a
does not always cause luteolysis (13). Uterine
biopsies in queens with pyometra after treatment

ties, which can reach up to 20% (12,14.15,17).

have not been studied, but a signifi-cant effect on

Surgical techniques are reviewed elsewhere extensively (34,38,41). In stump pyometra, excision is
recommended (9) with examination of the ovarian

the

stumps for presence of retained ovarian tissue

(14). Other techniques documented are hysterectomy and uterine drainage tubes (5), although these
procedure are not recom-mended (8).

Medical treatment
The medical approach is carried out with natural
prostaglandin F2a. It can be used in queens that

endometrium

is

not

expected

and

the

underlying CEH does n ot disappear. Moreover,

pyometra can show recurrence after treatment with
PGF2a. In one study 14% of the queens treated
with PGF2a showed recurrence of pyometra.
Therefore, is desirable to recommend castration as
soon as possible (10,36).

It has not been proven in cats completely, but

probably prostaglandins cause myometrial contractions, which evacuate uterine contents. This
myotonic effect increases intrauterine pressure and

have value in reproduction programs, are in stable

health status (without sepsis or peritonitis suspici-

in women a progressive reduction of prostaglandins receptors in the endometrial smooth muscle

on) and have open-cervix pyometra (2,5,10,12,

toward

In spite of the fact that there has been a

the cervix

has

been determined

(5).

certain grade of success of this method in dogs

Contraction of the uterus could result in expulsion

of the contents (5). PGF2a administration is contra-

with closed-cervix pyometra (25-34%), in general

indicated in pre-existent uterine rupture It can

has not been successful in cats (2). Medical

predispose uterine rupture in queens with closedcervix pyometra (12). In women and rabbits there

21).

it

therapy is recommended for elderly patients because of higher surgical and anaesthetic risk as far as

has been observed a relaxation of the uterine

180

cervix, but this has not been seen in cats.

when therapy has been finished after improvement

Patients undergoing such therapy must be hospita-

of most of the clinical signs. Follow-up must be

done 2 weeks after discharge. No or only very

lized according to their clinical status (5,8,40).

The treatment protocol with PGF2a is from 0,1 to
0,25 mg/kg SCT SID or BID. The dose depends

little vaginal secretion and absence of uterine

enlargement confirmed by imagenologic tests

mainly on clinical signs. The volume of vulvar

discharge should increase as the uterus empties.
The discharge usually becomes less purulent and
more mucoid or hemorrhagic as treatment conti-

should be observed (5). Most of the treated queens

nues (13). Treatment must continue till the vulvar

discharge stops and the uterus returns to its normal
size, and this can be expected between 3 to 5 days

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after treatment.

Treatment can be continued for more than 5 days

if the uterus is not yet empty (13) and must only
be performed if the clinical status is adequate (5).
Minimal therapeutic doses in queens have not been
established, but it has been observed that the

response to higher doses (0,25 mg/kg BID (14) is

not more beneficial than that to the normal, generally accepted and recommended dose of 0,1

mg/kg SID during 5 to 7 days (5,12,36,40). Care

must be taken to give adequate antibiotic and fluid
therapy (39). Other reports suggest doses about 50
pg/kg TID or QID or another of 200 to 500 pg/kg
SID or BID.

Doses of 0,5 or 1 mg/kg SC BID, once in two

days after day 40 of pregnancy, or five daily IM
injections of 2 mg per cat after day 33 of pregnancy, have been reported to result in complete luteolysis and abortion within 1 to 6 days after the first
injection, suggesting that such treatment also may

be effective for inducing luteolysis in pyometra

(14). Because of little information available on
induction of luteloysis in the cat with pyometra

and the risk of the use of luteolysis

inducing

drugs, the main aim must not be luteolysis but

uterine evacuation, which is usually very beneficial
in the cat (14).
Natural PGF2 is the only prostaglandin which has

been evaluated for the use in felines (5). Other

more potent prostaglandins
(i.e.
synthetic
substances like closprostenol) have not been
evaluated
and
can not substitute natural
.

prostaglandins. Their use in cats could end in a

fatal response because the safe and effective dose
has not been established (2,12).

In queens with open-cervix pyometra, the prognosis of recovery acute disease and future pregnancy
viability is excellent. The rate of short term
success is 82 to 100% (5,12), which is achieved

(95%)

return

to

normal

estrous

cycles

and

successful mating resulting in pregnancy (nearly

85%) (12,13,14,39). In those patients treated with
prostaglandins, care must be taken when breeding
the next estrous so that possible complications can
be avoided when consecutive effects of progesterone in a no gravid uterus are present (2,5).
It is suitable to carry out the OVH immediately in

those patients with close-cervix pyometra, where

the opening does not take place after some days of
treatment and the patient's condition deteriorates
(40).

At therapeutic range, PGF2a can cause some side

effects in most of the queens. All these effects are
dose dependent and obey physiologic actions of the
endogen prostaglandins and include vasodilatation,
haemostasis, pulmonary vasoconstriction and bronchodilation, gastroenteric tract secretion, increase
in renal blood flow and glomerular filtration rate,
inflammation, hyperalgesia, fever, smooth muscular activity (myometrium, gastrointestinal tract,
urinary bladder, tracheobronchial tract) (5). The
signs include vocalization, panting, restlessness,
salivation, urination, defaecation, tenesmus, diarrhoea, emesis, mydriasis, grooming, lordosis and
kneading (2,5,12,13,40).
These effects can occur soon after administration,
but cease after 1 hour (39). Signs decrease in
severity and intensity in the subsequent applications. That is the reason not to interrupt the treatment at the beginning (2,5,12). Uterine rupture or
leakage of the intraluminal contents into the abdomen via the uterine tubes is possible (13,33). For

several reasons, this could occur more often in

cats than in dogs: 1)in, cats, uterine rupture with
generalized peritonitis can occur before treatment
(in about 4% of the cases), 2)feline pyometra is
sometimes seen in conjunction with uterine torsi-

on, a condition that would greatly increase the

chance of rupture and finally, the uterine exudate
found in cats with pyometra is occasionally very
viscous and hard to be expelled.

LD50 in cats has not been reported as in dogs

(5,13 mg/kg) (38). Overdose from 1 to 5 mg/kg,
can produce ataxia and severe respiratory distress,
but not death (13).

181

Other drugs like oxytocine, ergometrina and estrogens have been used with limited responses (37).

Conclusions
Feline CEH-pyometra complex behaves differently
compared to the canine counterpart, but there are
some similarities in the clinical signs and
diagnostic tools. There have been carried out some
studies to achieve a histological classification,
which is very important to clarify different stages
of the disease.

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The disease can be treated successfully medically,

although to avoid secondary effects of the disease
and adverse effects of therapeutic prostaglandins,
the ideal approach is still the surgerical therapy.

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