What is the recommended procedure for removing an infected Intrauterine Device (IUD)?

Management of an Infected Intrauterine Device (IUD)

When an IUD is associated with pelvic inflammatory disease (PID), the device does not need to be removed immediately if the woman needs ongoing contraception. Instead, start antibiotics first, then reassess in 24-48 hours and consider removal if no clinical improvement occurs. 1

Initial Management Algorithm

1. Diagnosis of Infection

   • Confirm PID diagnosis through clinical assessment (fever, abdominal pain, uterine tenderness)
   • Obtain appropriate cultures if possible before starting antibiotics

2. Treatment Approach

   • Begin appropriate antibiotic therapy according to CDC Sexually Transmitted Diseases Treatment Guidelines 1
   • Provide comprehensive management for PID, including counseling about condom use
   • Do not immediately remove the IUD if ongoing contraception is desired

3. Follow-up Assessment (24-48 hours)

   • If clinical improvement: continue antibiotics and maintain IUD
   • If no clinical improvement: continue antibiotics and consider IUD removal
   • If patient wishes to discontinue IUD: remove after antibiotics have been started to reduce risk of bacterial spread 1

Evidence Supporting This Approach

The CDC guidelines provide clear recommendations based on systematic reviews of multiple studies. Treatment outcomes generally do not differ between women with PID who retain the IUD versus those who have it removed, provided appropriate antibiotic treatment and close clinical follow-up are implemented 1.

Evidence from randomized trials shows:

• One study found women with IUDs removed had longer hospitalizations than those who did not, with no differences in PID recurrences or subsequent pregnancies 1
• Another trial showed no differences in laboratory findings between IUD removal and retention groups 1
• A prospective cohort study showed no differences in clinical or laboratory findings during hospitalization, though the IUD removal group had longer hospitalizations 1

Special Considerations

When IUD Strings Are Not Visible

If the IUD strings are not visible and cannot be retrieved safely:

• Perform ultrasound examination to determine IUD location 1, 2
• If not visualized in the uterus, obtain abdominal X-ray to check for extrauterine location 2
• Surgical removal (preferably laparoscopy) is recommended for migrated IUDs 2

For Actinomyces Colonization

• Actinomyces-like organisms on Pap smear without symptoms do not require antimicrobial treatment or IUD removal 3, 4
• Pelvic actinomycosis is extremely rare but can occur with long-term IUD use (typically >5 years) 3
• IUDs should be changed at least every five years to limit risk of developing pelvic actinomycosis 3

Common Pitfalls to Avoid

1. Premature IUD removal: Removing the IUD before starting antibiotics may increase risk of bacterial spread 1

2. Inadequate follow-up: Close clinical monitoring is essential; reassessment within 24-48 hours is recommended 1

3. Unnecessary removal for asymptomatic colonization: In the absence of symptoms, women with Actinomyces-like organisms on Pap test do not need antimicrobial treatment or IUD removal 4

4. Failure to consider alternative contraception: If the IUD is removed, consider emergency contraception if appropriate and counsel on alternative contraceptive methods 1

By following this evidence-based approach, clinicians can effectively manage infected IUDs while minimizing unnecessary interventions and maintaining contraceptive coverage when desired by the patient.