Post-colpocleisis pyocolpos: Three case reports

Abstract

Colpocleisis is a procedure to safely manage advanced pelvic organ prolapse, particularly in older individuals and those who are medically compromised. An exceptionally uncommon and underreported infection-related complication following colpocleisis is postoperative pelvic abscess. This case series describes the clinical presentation and diagnostic challenges, along with the management approaches of this unusual complication. Three women in their early 70s, with prior comorbidities, developed pelvic abscesses 10–15 days after colpocleisis. All three presented with systemic inflammatory signs, including fever, leukocytosis, and elevated inflammatory markers. One of the women also developed a concurrent urinary tract infection. Diagnosis was confirmed by transperineal ultrasonography and contrast-enhanced computed tomography. Management involved surgical drainage through colpotomy with reopening of the obliterated vaginal canal. Purulent material was thoroughly evacuated. Cultures of abscesses revealed polymicrobial infections in all cases. One patient with septic shock had an additional positive bloodstream culture.

Pyocolpos is an uncommon yet serious infectious complication following colpocleisis that is more commonly observed as a consequence of post-hysterectomy vaginal cuff hematoma. Clinicians should be extremely cautious when examining postoperative febrile patients, even when common illnesses such as urinary tract infections are present. In this case series, surgical drainage and tailored antibiotic therapy resulted in full remission of all three patients without compromising prolapse repair or triggering recurrence. Future studies are required to guide the best course of management.

Highlights

• •Colpocleisis is a safe obliterative procedure, particularly in older medically frail women.
• •Postoperative pelvic abscess, or pyocolpos, is an exceedingly rare but serious complication following colpocleisis.
• •Early recognition, imaging, and combined surgical-antibiotic management are important in preventing morbidity
• •Clinicians should maintain a high index of suspicion for pelvic abscess in post-colpocleisis patients with signs of systemic infection.

1. Introduction

Colpocleisis is a well-established and extremely efficient obliterative technique for the treatment of advanced pelvic organ prolapse (POP) (1), particularly in older or medically frail women who are no longer sexually active (2). The procedure has a reported success rate ranging from 91 % to 100 %, and a low total complication rate, usually between 6 % and 15 % (3,4). The operation removes the vaginal canal, which lowers the postoperative risks that come with reconstructive POP surgeries (5,6).

Although this procedure is safe, infections may occur after surgery. Urinary tract infections and hematomas are very common, but pelvic abscesses or pyocolpos after colpocleisis are very rare (7), with few reports of pelvic abscesses following colpocleisis ([8], [9], [10]). A delayed or unusual presentation may result from the absence of a patent vaginal canal, which inhibits the natural drainage of a postoperative accumulation of fluid.

Three patients in their 70s who had total colpocleisis and subsequently developed pelvic abscesses are presented in this case series. In addition to examining the possible causes of these unusual complications, the aim is to clarify the clinical features, diagnostic challenges, and surgical management of this condition.

2. Case Presentations

2.1. Case 1

A 73-year-old multiparous woman (gravida 7, para 7) with a history of hypertension and coronary artery disease presented to the emergency department 12 days after a concomitant total vaginal hysterectomy and total colpocleisis performed for stage IV POP. Given her age, significant comorbidities, and absence of sexual activity, an obliterative procedure (colpocleisis) was deemed more appropriate than reconstructive repair. Her postoperative recovery was initially uneventful until the onset of symptoms on postoperative day 10. She reported a 48-h history of progressive lower abdominal pain, fever, and nausea.

On examination, the patient was hypotensive (a notable deviation from her baseline hypertension), tachycardic, and hypoxemic, raising concern for septic shock. Abdominal examination revealed suprapubic tenderness without rebound or guarding. Laboratory investigations demonstrated leukocytosis, with a white blood cell (WBC) count of 23,400/mm³, an elevated erythrocyte sedimentation rate (ESR) of 91 mm/h, and a markedly increased C-reactive protein (CRP) level of 112 mg/L.

Pelvic ultrasound revealed a 50 mL heterogeneous hypoechoic collection along the posterior vaginal wall. A contrast-enhanced abdominopelvic computed tomography (CT) scan was performed to further delineate the collection and exclude visceral injury, given the patient's systemic signs of sepsis. It confirmed an 8 * 6 cm gas- and fluid-containing abscess located in the rectovesical pouch at the surgical site, with diffuse pelvic fat stranding but no evidence of bowel perforation (Fig. 1).

Fig. 1.

Axial CT scan of the pelvis (case 1) showing abscess and inflammatory changes (a: gas-containing fluid collection with enhanced wall and surrounding fat haziness, b: urinary bladder, c: bowel loop).

The patient was promptly taken to the operating room for surgical exploration. Under general anesthesia, under digital guidance through the rectum, the colpocleisis sutures were carefully released. As two to three rows of sutures were opened, purulent discharge began to drain, and the cavity progressively expanded in the direction of the discharge. The sutures were sequentially excised along the tract until the entire abscess cavity was adequately accessed. Approximately 80 mL of purulent fluid was evacuated, and a subsequent ultrasound confirmed complete drainage. The cavity was then thoroughly irrigated with approximately two liters of normal saline. Intravenous empirical broad-spectrum antibiotics that were initiated before surgery were continued and later adjusted based on culture results. Blood cultures yielded Pseudomonas species, while abscess fluid cultures grew Staphylococcus aureus and Escherichia coli, consistent with a polymicrobial infection.

In the following days, daily transvaginal examinations were performed to ensure continued drainage and to maintain patency of the distal tract until complete resolution was achieved. The patient demonstrated rapid clinical improvement following surgical drainage and targeted antimicrobial therapy. Inflammatory markers normalized, and her hemodynamic parameters stabilized. The vaginal canal re-closed spontaneously within two weeks without further intervention. At six-month clinical follow-up, she remained asymptomatic, with no evidence of infection or prolapse recurrence.

2.2. Case 2

A 72-year-old woman arrived at the clinic exhibiting a high-grade fever (38.8 °C), chills, and vaginal discharge. Ten days earlier, she had had a total vaginal hysterectomy, a bilateral salpingo-oophorectomy (BSO), a total colpocleisis, and a high perineorrhaphy for stage III POP. She had a history of high blood pressure and ischemic heart disease.

On physical examination, she was tachycardic (117 bpm) and relatively hypotensive (90/60 mmHg). A digital rectal examination revealed a palpable mass about 2 cm above the anorectal ring on the anterior wall of the rectum. Laboratory tests showed leukocytosis (WBC count 14,200/mm³), an increased ESR (97 mm/h), and a CRP level of 232 mg/L. Contrast-enhanced abdominopelvic CT revealed an 11 * 8 * 8 cm thick-walled abscess harboring gas and fluid within the deep pelvic cavity, situated posterior to the urinary bladder (Fig. 2, Fig. 3).

Fig. 2.

Axial CT scan of the pelvis (case 2) illustrating the abscess and bladder (a: gas-containing fluid collection with enhanced wall and surrounding fat haziness, b: urinary bladder).

Fig. 3.

Sagittal CT scan of the pelvis (case 2) demonstrating the abscess and bladder (a: gas-containing fluid collection with enhanced wall and surrounding fat haziness, b: urinary bladder).

Empirical broad-spectrum intravenous antibiotics were initiated, followed by surgical intervention. Under general anesthesia, the colpocleisis sutures were gently released, and the abscess was drained with the use of ultrasound guidance. No additional sutures were placed after evacuation. The patient showed quick clinical improvement within three days of surgery, and antibiotic medication was then adjusted based on culture and sensitivity results. At six-month follow-up she remained asymptomatic, with no recurrence or problems.

2.3. Case 3

A 71-year-old woman (gravida 3, para 3) with a history of hypertension, coronary artery disease, and type 2 diabetes mellitus who had had a total vaginal hysterectomy (TVH) and total colpocleisis for stage III POP 15 days earlier came to the hospital with a fever, chills, and worsening pain in her lower abdomen. Her vital signs were within normal limits. The laboratory tests showed a strong inflammatory response, with a WBC count of 16,300/mm³, an ESR of 106 mm/h, and a CRP level of 250 mg/L. Blood cultures did not show any growth, but urine cultures showed an extended-spectrum beta-lactamase (ESBL) bacterium. Transperineal ultrasonography revealed a 52 × 60 mm hypo-heteroechoic collection in the rectovesical space, consistent with a pelvic abscess.

The patient underwent colpotomy and drainage of the abscess under general anesthesia, which involved reopening of the colpocleisis sutures as far as possible. Approximately 300 mL of purulent material was evacuated. Empirical broad-spectrum intravenous antibiotics (vancomycin and meropenem) were administered. Culture of the abscess fluid demonstrated polymicrobial growth, including Streptococcus spp., Enterococcus spp., and Escherichia coli. In light of these results and the concurrent ESBL urinary tract infection (UTI), antimicrobial therapy was de-escalated to ciprofloxacin and metronidazole.

The patient showed rapid clinical improvement, with resolution of fever and normalization of inflammatory markers. A follow-up transperineal ultrasound confirmed complete abscess clearance. She was discharged in stable condition and remained symptom-free without evidence of recurrence of prolapse at six-month follow-up.

3. Discussion

This case series describes the clinical presentation and diagnostic challenges of 3 patients with a rare complication, pyocolpos following colpocleisis. Pelvic abscesses, such as pyometra or pyocolpos, are uncommon but clinically important complications after colpocleisis. Their nonspecific symptoms, like low-grade fever, abdominal pain, and elevated inflammatory markers, can delay diagnosis by mimicking normal postoperative recovery or gastrointestinal diseases (8,[11], [12], [13]). All three patients in this case series and previously reported cases ([8], [9], [10]) presented with fever and elevated inflammatory markers following colpocleisis.

The pathogenesis of postoperative infection complications after colpocleisis is complicated, comprising a complex interplay of both patient-related and procedure-related factors. A study by Raina et al. (7) revealed that a concurrent hysterectomy after colpocleisis surgery significantly elevated the likelihood of overall complications (11.4 % vs. 9.5 % with an adjusted odds ratio of 1.93). Women undergoing colpocleisis usually have more health problems than those who undergo alternative prolapse treatments. This may contribute to the overall risk of complications, even though the procedure is generally safe (14). All three patients in this case series exhibited comorbidities alongside their medical histories.

A specific mechanism reported in cases involving concurrent hysterectomy is the possible formation of a vaginal cuff hematoma (15). Without a clear vaginal canal for drainage, this hematoma can be an ideal place for bacterial growth, which can further form a pyocolpos. These patient and procedural factors are important, but they do not undermine the importance of precise surgical technique and strict sterilization (16,17). The polymicrobial growth observed in the abscess culture indicates either an ascending contamination from the vagina or a secondary infection of a surgical hematoma.

The three cases highlight the critical importance of maintaining a high index of suspicion for postoperative infectious complications following colpocleisis. All three women were visited on the seventh postoperative day but developed systemic indications of inflammation, like fever, higher levels of inflammatory markers, and, in some cases, unstable blood pressure, between 10 and 15 days following surgery. This late presentation is probably due to the blockage of the vaginal canal, which stopped the natural drainage of fluid collections after surgery and allowed the infection to grow slowly. This process is similar to the delayed diagnosis seen in retroperitoneal abscesses (18,19).

All three women underwent conservative treatments for suspected viral infections before their referral. Case 3 showed an ESBL-producing UTI at the same time. Although UTI is the most prevalent infectious complication following this operation (4), linking the patient's septic or ill appearance exclusively to the UTI may result in a harmful delay in the diagnosis of the pelvic abscess. Consequently, every postoperative patient exhibiting systemic sickness or elevated fever necessitates thorough investigation for all possible origins, including the surgical site. The outcome of pyocolpos treatment rests on the combination of proper intravenous antibiotic therapy and efficient drainage (20).

Imaging is essential for the precise diagnosis of pyocolpos. As seen in case 1, a general abdominal ultrasound may not be sufficient to identify a pelvic collection. Transperineal sonography and pelvic CT scan were helpful both in finding the abscess and in facilitating treatment.

All three patients needed surgical drainage of a large and symptomatic abscess. A key step in surgery involved the reopening of the obliterated vaginal canal. In these cases, suture excision and open drainage were a safe and effective surgical approach, which is therefore recommended as a preferred management technique. In addition, as total colpocleisis completely closes the vaginal canal, it allows the vaginal discharge or hematoma to develop after a vaginal hysterectomy. Therefore, constructing a tiny channel, like the one utilized in partial colpocleisis, may prevent pyocolpos.

This case series provides reassuring long-term follow-up outcomes of the patients. One potential concern after reopening of the vaginal canal for abscess drainage is the risk of recurrent POP. However, none of the patients in this series experienced a return of prolapse. This is probably because total colpocleisis, which fully obliterates the vaginal canal and its supporting structures, is permanent. Since there was no mucosal lining in the area that was reopened during drainage, it easily re-adhered and closed on its own postoperatively. All three patients remained asymptomatic and showed no symptoms of recurrence at the six-month follow-up, and the vaginal canal reclosed without the need for additional suturing.

In conclusion, this case series alerts clinicians to early detection and timely treatment of pyocolpos as a rare but serious postoperative complication following colpocleisis. These cases provide important information about how to deal safely with this rare complication and may help doctors in decision-making for future surgeries.

Contributors

Kasra Akbari contributed to the conception of the case reports, acquiring and interpreting the data, drafting the manuscript and undertaking the literature review.

Mansooreh Yaraghi contributed to patient care, conception of the case reports, acquiring and interpreting the data, drafting the manuscript, undertaking the literature review and revising the article critically for important intellectual content.

Both authors approved the final submitted manuscript.

Patient consent

Written informed consent for the publication of the report and accompanying images was obtained from all three patients.

Provenance and peer review

This article was not commissioned and was peer reviewed.

Declaration of generative AI and AI-assisted technologies in the writing process

As native Persian speakers, we used generative AI to edit grammar and enhance the readability of the manuscript; however, this technology was applied with human oversight and control, and we carefully reviewed and edited the output, recognizing that AI can produce authoritative-sounding content that may be incorrect, incomplete, or biased. The authors remain fully responsible and accountable for the final work.

Funding

This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare that they have no competing interest regarding the publication of this case report.