Pyometras are uncommon conditions. The majority of patients with pyometras are postmenopausal women. Huge pyometras may develop with obliteration of the fallopian tubes and obstruction of the cervix, and interfere with spontaneous drainage of the uterine cavity. Approximately 25% of women with pyometras have associated malignancies [1] . Intrauterine devices (IUDs) in postmenopausal women are a known risk factor for pyometras [2, 3] . Spontaneous perforation of a pyometra usually presents

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... ally with an acute abdomen, peritonitis, or pneumoperitoneum and may be potentially fatal [4] . Here, we report a patient with a huge, asymptomatic pyometra and review the treatment options for this disease. A 78-year-old woman came to our clinic for evaluation of an abdominal mass, which she had noted for >30 years. She lived alone in a rural country setting. She had eight children, and an IUD was inserted after the delivery of her last child. She had never changed or removed the IUD. A palpable abdominal mass and occasional lower abdominal pain had been noted for many years, but she did not seek evaluation. She visited our clinic at the request of her family. She was afebrile and had no abdominal pain, but had a distended abdomen. The abdomen was soft and ovoid. A large, soft, movable mass (approximately 20 cm in length) occupied the whole abdomen. There was no tenderness, and the bowel movements were normal. Imaging studies, including a computer tomographic scan and an ultrasound, revealed an abdominal cystic mass with a thickened wall (approximately 20 cm 11 cm 10 cm; Fig. 1 ). The mass consisted of homogenous, fine, internal echoes. No ascites was noted. Several pieces of opaque rodlike material were located near the bottom of the mass. The pelvic examination revealed a smooth cervix with an obstructed cervical os. There was no leukocytosis or signs of infection. Tumor markers, including CA125, CEA, AFP, and E2, were all within normal limits. Based on a suspected huge pyometra with an IUD or a pelvic malignancy, a laparotomy was performed. Intraoperatively, a large uterus with a smooth surface without erythematous changes was observed. A small hole was made and approximately 2000 mL of the purulent material was drained. Intrauterine hemorrhage was noted after drainage of the uterus. An IUD was identified near the cervix. A hysterectomy was performed, and the postoperative course was uneventful. The abdominal wound healed well and the patient was discharged 7 days later with a stable condition. The pathology report confirmed a pyometra with no evidence of malignancy. Culture of the purulent material grew Bacteroides fragilis and Streptococcus viridans. The risk factors for pyometra include benign and malignant tumors, radiation cervicitis, atrophic cervical stenosis, congenital anomalies, and IUDs. Chan et al [1] reported that 22.2% of patients with pyometras in Hong Kong between 1993 and 1999 were associated with malignancies and 74.1% were idiopathic. Lien et al [2] reported seven cases of pyometras within a 5-year period in northern Taiwan, and two of the seven cases (18.6%) were IUD-related. IUDs are more popular in Asia as a method of contraception compared with other methods [5] . Because of the longer life expectancy of women, retained IUDs in postmenopausal women may play an important role in the occurrence of pyometras. The classic triad of symptoms in patients with pyometras includes purulent vaginal discharge, postmenopausal bleeding, and lower abdominal pain. Nevertheless, asymptomatic patients with pyometras have been reported [6] . The spontaneous rupture of pyometras is a rare event, but the majority of such cases become a life-threatening emergency [2e4,7]. Only 22 cases of spontaneous perforation of pyometras were reported in the English literature between 1980 and 2004, and 35% of the cases were associated with malignant diseases [4]. Our patient was at a high risk for perforation of the pyometra because the mass was so large. Indeed, it is surprising that our patient has had a stable condition for so many years. Dilatation of the cervix and uterine drainage constitute the most common method of treatment for patients with pyometra [1] . Some of the patients have persistent pyometras, thereby