What is the appropriate management for a patient with an IUD experiencing pelvic pressure, malodorous discharge, and fever?

Urgent Evaluation and Treatment for Suspected Pelvic Inflammatory Disease

This patient requires immediate in-person evaluation with testing for sexually transmitted infections, initiation of empiric antibiotic therapy for presumed pelvic inflammatory disease (PID), and close follow-up within 24-48 hours, with the IUD initially remaining in place unless she fails to improve clinically. 1

Immediate Assessment Required

The combination of pelvic pressure, malodorous discharge, and fever in an IUD user strongly suggests PID, which requires urgent evaluation to prevent serious morbidity including tubo-ovarian abscess, chronic pelvic pain, and infertility. 1

Key clinical findings to assess:

• Temperature and vital signs to determine severity 1
• Pelvic examination for cervical motion tenderness, adnexal tenderness, and uterine tenderness 1
• Visualization of IUD strings and assessment for displacement 1
• Pregnancy test to rule out ectopic pregnancy or intrauterine pregnancy with IUD in situ 1

Diagnostic Testing

Obtain the following tests before or at the time of examination:

• Nucleic acid amplification testing for chlamydia and gonorrhea 2
• Wet mount for bacterial vaginosis and trichomonas 2
• Pregnancy test 1
• Complete blood count if systemic symptoms are present 1

Initial Management Algorithm

Start empiric antibiotic treatment immediately according to CDC STD Treatment Guidelines without waiting for test results. 1

The IUD should NOT be removed immediately, even with suspected PID. 1 This is a critical point where clinical practice has evolved based on evidence showing that treatment outcomes do not generally differ between women who retain the IUD versus those who have it removed. 1

IUD Management Decision Tree:

At 24-48 hours reassessment:

• If clinical improvement occurs: Continue antibiotics, keep IUD in place, complete full antibiotic course 1
• If NO clinical improvement occurs: Continue antibiotics AND consider IUD removal at this point 1
• If patient requests removal: Remove IUD after antibiotics have been started to avoid bacterial spread from the removal procedure itself 1

Critical Pitfalls to Avoid

Do not remove the IUD before starting antibiotics - removal can cause bacterial spread and worsen infection. 1 If removal is necessary, it must occur after antibiotic therapy has been initiated. 1

Do not delay treatment waiting for culture results - empiric treatment should begin immediately based on clinical presentation. 1, 2

Do not assume the IUD must come out - systematic reviews show that women with PID who retain the IUD have similar outcomes to those with removal, though one randomized trial showed higher recovery rates with removal. 1 The key is appropriate antibiotic treatment and close follow-up. 1

Comprehensive PID Management

Provide counseling about:

• Condom use to prevent reinfection 1
• Partner notification and treatment 1
• Return precautions: heavy bleeding, worsening pain, fever, or abnormal discharge 1

If IUD is ultimately removed:

• Consider emergency contraceptive pills if recent unprotected intercourse 1
• Counsel on alternative contraceptive methods 1
• Offer another contraceptive method if desired 1

Special Considerations

The risk of PID with IUDs is highest in the first 20 days after insertion, but can occur at any time, particularly with acquisition of new sexually transmitted infections. 2 The slightly elevated PID risk exists only in the first month following insertion in contemporary IUD users. 3

Actinomyces colonization (which can occur with long-term IUD use) rarely causes serious pelvic actinomycosis but can present similarly to PID and may require IUD removal and prolonged penicillin therapy. 4 However, routine Pap smears showing Actinomyces in asymptomatic women do not require IUD removal. 5