Post-IUD Removal Management with Worsening Pain and Discharge
This patient requires urgent evaluation for endometritis or retained IUD fragments, with immediate initiation of broad-spectrum antibiotics if infection is suspected, and pelvic ultrasound to rule out retained products or complications. 1, 2
Immediate Assessment Required
The worsening pain and pink stringy discharge following IUD removal are concerning for:
- Post-removal endometritis - The most likely diagnosis given the temporal relationship and symptom progression, particularly with pink stringy discharge suggesting inflammatory exudate mixed with blood 3, 4
- Incomplete removal or retained fragments - Must be excluded via ultrasound, as embedded IUDs can leave fragments that cause ongoing inflammation 1, 2
- Uterine perforation during removal - Though less likely if removal was uncomplicated, worsening pain mandates consideration 5
Diagnostic Workup
Perform the following immediately in the emergency department:
- Transvaginal ultrasound to confirm complete IUD removal and assess for retained fragments, uterine perforation, or developing abscess 1, 2, 5
- Pelvic examination specifically evaluating for cervical motion tenderness, adnexal tenderness, and purulent cervical discharge suggesting ascending infection 3
- Wet mount and cervical cultures for sexually transmitted infections (gonorrhea, chlamydia) and evaluation of vaginal secretions for leukocytes, which improves diagnostic accuracy for pelvic inflammatory disease 6, 3
- Complete blood count and inflammatory markers if systemic infection is suspected 3
Treatment Algorithm
If Infection is Suspected (Most Likely Scenario):
Initiate empiric broad-spectrum antibiotic therapy immediately given the clinical presentation of worsening pain and abnormal discharge post-IUD removal 3, 4:
- Admit for parenteral antibiotics if the patient has severe pain, fever, or signs of upper genital tract infection, as anaerobic organisms are common with IUD-associated infections 3
- Outpatient treatment may be considered only if symptoms are mild, with a beta-lactam antibiotic followed by doxycycline to cover N. gonorrhoeae and C. trachomatis 3
- Add anaerobic coverage (such as metronidazole or clindamycin) given the IUD association, as bacterial invasion following microtrauma is well-documented 3, 4
If Ultrasound Shows Retained Fragments or Malposition:
- Remove any retained IUD material immediately, as this perpetuates inflammation and infection risk 1, 2
- Continue antibiotic therapy as above 3
If Perforation is Identified:
- Urgent surgical consultation for laparoscopic removal, as perforated IUDs must be removed as soon as possible 5
Critical Red Flags Requiring Admission
The patient should be hospitalized if any of the following develop:
- Severe or worsening pelvic pain despite initial management 1, 2
- Fever or signs of systemic infection 1, 3
- Heavy bleeding beyond normal post-removal spotting 1, 2
- Suspected tubo-ovarian abscess on imaging 3
- Generalized peritonitis suggesting rupture or severe infection 3
Post-Treatment Counseling
- Return immediately for heavy bleeding, severe cramping, fever, or worsening discharge 1, 2
- Alternative contraception counseling should be provided once acute symptoms resolve 1, 2
- Follow-up within 48-72 hours to ensure symptom resolution and review culture results 1
Common Pitfalls to Avoid
- Do not assume normal post-removal symptoms when pain is worsening rather than improving - this suggests pathology 1, 2
- Do not delay antibiotics while awaiting culture results if clinical suspicion for infection is high, as untreated salpingitis has significant fertility consequences 3
- Do not perform routine cultures of asymptomatic removed IUDs, but in this symptomatic patient, cultures are indicated 7
- Do not overlook actinomycosis, though rare, as it can present with mild PID symptoms in IUD users and requires specific penicillin therapy 8