a 60-year - old female presented with a history of serosanginous discharge and bleeding ( small amount ) per vaginum for the last 4 months . she was postmenopausal for the last 10 years with p5 + 1 + 0 + 5 . local examination revealed hard infiltrative growth destroying both cervical lips and involving the vaginal wall . the upper third of the lateral and upper half of the anterior and posterior walls of the vagina were involved . hemogram ( hb  =  11.4  gm% , tlc  =  7600/l ) and renal function tests ( urea  =  24  mg / dl and creatinine  =  0.81  mg / dl ) were normal . ultrasound of the abdomen and pelvis showed no intra - abdominal / pelvic collection or pyometra . with carcinoma cervix iii b ( figo clinical staging ) , she was planned for external radiotherapy ( 46gy in 23 fractions over 4.5 weeks ) . but after receiving 18gy/9 fractions , she presented with pain in the abdomen and vomiting . contrast - enhanced ct showed multiple pelvic and intra - abdominal collections , a dilated endometrial cavity with breach at the uterine fundus and its continuation with large pelvic collection , suggestive of perforated pyometra . sagittal and coronal reformats in multi - detector ct depicted the site and size of the uterine breach . the patient was managed with pigtail drainage of the larger pelvic and subhepatic collections , and with appropriate antibiotic cover ( cefoperozone , sulbactam and amikacin ) . she improved clinically and follow - up ultrasound after 1 week showed near complete resolution of the abscesses , and the catheter was taken out ( fig . 1 and 2 ) . 
 figure 1contrast - enhanced axial ct images showing dilated endometrial cavity with site of the breach at uterine fundus ( arrow ) . pelvic collections ( * ) are seen with the abdominal / mesenteric extension and resultant intra - abdominal collections ( * ) . figure 2contrast - enhanced coronal and sagittal reformatted ct image depicting dilated endometrial cavity with site and size of the breach at uterine fundus ( arrow ) . contrast - enhanced axial ct images showing dilated endometrial cavity with site of the breach at uterine fundus ( arrow ) . pelvic collections ( * ) are seen with the abdominal / mesenteric extension and resultant intra - abdominal collections ( * ) . contrast - enhanced coronal and sagittal reformatted ct image depicting dilated endometrial cavity with site and size of the breach at uterine fundus ( arrow ) . pyometra is an uncommon condition occurring mainly in elderly postmenopausal females , and results when natural drainage of the uterine cavity is compromised . the common causes of pyometra include malignant condition of the genital tract and sequele of their treatment , benign conditions such as infection and congenital cervical anomalies . the benign or malignant conditions cause accumulation of secretions and gradual enlargement of the uterus , leading to thinned uterine walls which may be sloughed with spontaneous uterine rupture and causing generalized peritonitis . spontaneous uterine perforation is rare and extensive review of the english literature has revealed only 26 such reported cases to date . furthermore , spontaneous rupture of pyometra in cervical cancer presenting as generalized peritonitis is extremely rare and only four cases have been described . we reviewed all the cases of spontaneous uterine perforation in cervical cancer and the findings are summarized in table 1 . no.agesymptomsprovisional diagnosisperforation sitehistologytreatment867ap , gbgpfundussquamous cell carcinomaaspiration and drainage234apgp , ppleft corneal regionsquamous cell carcinomadrainage and pl272apgpfundussquamous cell carcinomadrainage and pl160ap , fgpfundussquamous cell carcinomatah with bsopresent case60ap , f , vgpfundusadeno - carcinomapigtail drainageap , abdominal pain ; bso , bilateral salpingo - oophorectomy ; f , fever ; gb , genital bleeding ; gp , generalized peritonitis ; pl , peritoneal lavage ; pp , perforated pyometra ; tah , total abdominal hysterectomy ; v , vomiting . cases of spontaneous uterine perforation in cervical cancer ap , abdominal pain ; bso , bilateral salpingo - oophorectomy ; f , fever ; gb , genital bleeding ; gp , generalized peritonitis ; pl , peritoneal lavage ; pp , perforated pyometra ; tah , total abdominal hysterectomy ; v , vomiting . the most common perforation site was the uterine fundus and in only one case it was the uterine cornual region . ct features of perforated pyometra have been described in only one case in which ct revealed the diagnosis and surgical intervention was performed . in our case , the patient presented with features of generalized peritonitis , ct showed perforated pyometra at the uterine fundus with multiple pelvic and intra - abdominal collections . sagittal and coronal reformats in multi - detector ct are very helpful in depicting the site and size of uterine breach , demonstrating the resultant intra - abdominal collections and staging of cervical cancer . the site of uterine breach can be missed on axial images as it is usually seen in fundus ; hence , in elderly postmenopausal females with peritonitis sagittal and coronal reformats of uterus should be carefully evaluated . sonography plays a limited role in the diagnosis of ruptured pyometra because of its inability to demonstrate the uterine breach and the limited sonographic window available due to perforation . treatment of ruptured pyometra in cervical cancer patients varies depending on the clinical condition of the patient and the preoperative diagnosis . in most cases drainage of the collections was carried out , except for one case in which total abdominal hysterectomy and bilateral salpingoophorectomy were peformed . the index case was managed by putting percutaneous pigtail catheters in pelvic and subhepatic collections . spontaneous rupture of pyometra in cervical cancer is very rare and should be considered in elderly postmenopausal women with cervical cancer presenting with an acute abdomen . multi - detector ct with sagittal and coronal reformatted images could play an important role in the diagnosis of ruptured pyometra .