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Pyometra in the Queen to Spay Or Not to Spay?

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Pyometra in the Queen to Spay Or Not to Spay? 21_33_Pyometra_Hollinshead.qxp_FAB 03/12/2015 12:41 Page 21 Journal of Feline Medicine and Surgery (2016) 18, 21–33 CLINICAL r e v i e w Pyometra in the queen To spay or not to spay? Fiona Hollinshead and Natali Krekeler Introduction Practical relevance: Pyometra is a commonly occurring uterine disease Pyometra is an acute or chronic suppurative inflammation of the uter- in cats that often leads to loss of ine wall in intact queens. It is characterised by endometrial hyperplasia breeding potential and, in some cases, with cystic dilation of endometrial glands and accumulation of puru- can be life threatening. An increased lent exudate in the uterine lumen. The disease is most often observed in incidence of cystic endometrial hyperplasia (CEH) dioestrus or ‘pseudopregnancy’ in the queen, which is a phase of prog- and pyometra is seen with age. Most queens esterone dominance that lasts approximately 40 days. The relatively present with uterine lesions after 5–7 years of age long progesterone-dominated dioestrous phase occurs in queens that (average 7.6 years, range 1–20 years). Clinical signs undergo ovulation (induced or spontaneous) and predisposes them to most commonly occur within 4 weeks of the onset the development of cystic endometrial hyperplasia (CEH) and subse- of oestrus in queens that are either mated, spontaneously ovulate or are induced to ovulate Incidence of feline pyometra (mechanical stimulation or hormone induction). The disease is most often observed in dioestrus. A recent study from Sweden reported that 2.2% of intact queens were diagnosed with Clinical challenges: Queens with pyometra often pyometra by the age of 13 years.1 The incidence of pyometra is considered to be lower go undiagnosed as there may be few or only very in queens than in bitches, as queens are induced ovulators. However, underestimation mild clinical signs and laboratory changes. For of disease incidence is likely because queens often do not express clinical signs to the example, the classic sign of mucopurulent bloody same extent as seen in bitches.2 Furthermore, it seems that, despite being induced vulvar discharge often goes unnoticed. Abdominal ovulators, spontaneous ovulation is not as uncommon in queens as originally thought. ultrasound is the best tool for diagnosis of There have been various reports of spontaneous ovulation in the queen, with inci- pyometra and for monitoring response to therapy. dence ranging from 30% up to 87%!3–5 Despite many hypotheses, the underlying Patient group: Classically, middle-aged/older cause of spontaneous ovulation in the queen is still unknown, but may be influenced nulliparous intact queens present with pyometra. by breed, increasing age and parity. Recently, a breed predisposition has been report- However, so-called ‘stump pyometra’ can occur ed, with Oriental purebred cats having a higher incidence of pyometra than domestic if ovarian tissue is left behind during ovariectomy and random-bred cats.1 This has also been observed by the authors. Oriental pure- or ovariohysterectomy (ovarian remnant syndrome). bred cats are additionally known to come into oestrus year-round and often have short Queens treated with exogenous steroid hormones interoestrus intervals (associated with overlapping follicular waves)6 compared with such as high doses of megestrol acetate or domestic shorthair and random-bred cats. Furthermore, Oriental queens have a higher medroxyprogesterone acetate for oestrus incidence of spontaneous ovulation than other cats. Therefore, the uterus of Oriental prevention can also develop CEH and pyometra. queens is exposed to more frequent oestrogen priming and periods of high proges- Evidence base: There has been little published terone concentration. These two factors are hypothesised to contribute to the higher to date on CEH, endometritis and pyometra incidence of pyometra in young Oriental breed cats compared with other cats of sim- in the queen and most of the currently available ilar age. In the aforementioned large Swedish retrospective study,1 the median age of information has been extrapolated from studies diagnosis of pyometra in Oriental/exotic purebred queens (Sphynx, Siberian, Ocicat, carried out in the bitch. The queen and the bitch Korat, Siamese, Ragdoll, Maine Coon and Bengal) was significantly lower (4 years; have very different reproductive physiology; thus, P <0.05) than that reported for the general cat population (>7 years).2 further research and investigation into the precise aetiopathogenesis of these disease processes of Fiona Hollinshead the uterus in the queen is warranted. BVSc(Hons) MACVS PhD Diplomate ACT* Audience: This review is aimed at clinicians GlenBred, Matamata Veterinary Services, 26 Tainui Street, Matamata 3400, New Zealand working in small animal practice, especially those in countries where surgical sterilisation is not Natali Krekeler Dr Med Vet PhD Diplomate ACT practised as commonly as in the United States, Faculty of Veterinary and Agricultural Sciences, Canada or Australasia, and who will therefore see The University of Melbourne, Werribee, VIC 3030, Australia a greater proportion of intact queens. *Corresponding author: [email protected] doi: 10.1177/1098612X15623114 © The Author(s) 2016 Downloaded from jfm.sagepub.com at ISFM on January 15, 2016 JFMS CLINICAL PRACTICE 21 21_33_Pyometra_Hollinshead.qxp_FAB 03/12/2015 12:41 Page 22 REVIEW / Pyometra in the queen quent pyometra caused by infection from could explain why we see pyometra in young bacteria ascending from the vagina. The most cats, which are unlikely to have underlying common bacterium involved in pyometra is uterine pathology such as CEH. in bitches, it is Escherichia coli. Similar to the bitch, regardless hypothesised that varying pathogenicity of of the underlying cause, the presence of proges - E coli strains might be responsible for the terone (endogenous or exogenous in source) development of CEH. No studies investigating facilitates the development of pyometra. the effects of bacterial pathogenicity in pyome- The incidence of feline pyometra (see box tra have been undertaken in cats. on page 21) is not well documented. The risk of Pathogenesis and aetiology: uterine disease Pivotal role of progesterone what comes first? Importantly, regardless of the underlying cause may increase of pyometra, the presence of progesterone Cats are classified as seasonally polyoestrus, with each (exogenous or endogenous) is required for coming into oestrus between spring and early pyometra to occur. This was confirmed in autumn with a seasonal anoestrus in winter non-pregnant a canine disease model where intrauterine (long-day breeders). The oestrous period or oestrous cycle, inoculation of a pathogenic strain of E coli in ‘call’ lasts 6–7 days. if ovulation (either induced oestrus or anoestrus did not result in pyometra or spontaneous) occurs but the queen does as the but inoculation of the same strain in dioestrus did.7 No comparable studies have been not become pregnant, there follows a period presence of of progesterone secretion (from the corpus published in the queen. luteum) for approximately 40 days. This is the fetuses is dioestrous phase (or so-called pseudopregnan- cy). Cats that undergo an anovulatory oestrus effectively What role do reproductive hormones play? will have an interoestrus interval of about 8–10 protective The majority of queens affected by pyometra days with baseline progesterone levels. are presented with clinical signs within 4 The pathogenesis of pyometra is incomplete- against the weeks of the onset of the latest oestrus. ly understood – both in the bitch and the Although there is no evidence that abnormal queen, but especially the queen being an development ovarian hormone concentrations are involved induced ovulator. in the bitch, pyometra is cur- of pyometra. in the pathogenesis of pyometra in queens or rently believed to be multifactorial in origin. it bitches, it has been shown that progesterone is is most likely similar in the queen. The aetiolo- necessary to initiate CEH and that oestrogen gy is similar in the two species, with proges- potentiates the effect by upregulating the terone influence predisposing the uterus to expression of progesterone receptors. ascending bacterial (most com- Therefore, pyo metra is believed monly E coli) infection. to be facilitated by an oestrogenic originally CEH and pyometra phase that is followed by a were defined as one disease enti- relatively long non-pregnant ty. it was believed that repeated pro gesterone-dominated phase exposure of the endometrium to (dioestrus caused by spon taneous high concentrations of oestrogen or induced ovulation). during proestrus and oestrus, Leukocyte inhibition, decreas - followed by high concentrations ed myometrial contractions and a of progesterone during the luteal closed cervix in the progesterone- phase (ie, dioestrus), led to the influenced uterus facilitate bac - development of CEH (Figure 1). terial growth in a non-gravid This, in turn, predisposed the uterus from ascending infection. uterus to ascending secondary Progesterone also stimulates bacterial infection and develop- uterine stromal and glandular ment of pyometra. More recently, epithelial proliferation and the question has been raised as to increases uterine glandular secre- whether pyometra and CEH are tions, which are an important actually two separate disease source of nutrients for the early entities. Although the conditions developing embryos/fetuses in have many similarities and can pregnant queens. These
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