What is the appropriate workup and examination for a patient with an intrauterine device (IUD) presenting with vaginal pressure, without vaginal bleeding or discharge?

From the Guidelines

For a patient experiencing vaginal pressure with an IUD in place but no bleeding or discharge, I recommend ordering a pelvic ultrasound (transvaginal and transabdominal) to confirm proper IUD placement and rule out complications. This approach is supported by the U.S. selected practice recommendations for contraceptive use, 2013, which suggests that if ultrasonography is available, it should be considered to determine the location of the IUD if the strings are not visible and cannot be retrieved safely 1. The pelvic ultrasound can help identify potential causes of pressure like fibroids, ovarian cysts, or pelvic organ prolapse. In terms of laboratory tests, a complete blood count (CBC), urinalysis, urine culture, and pregnancy test (serum hCG) are essential to exclude infection, pregnancy, or other systemic issues 1. The CBC can detect signs of infection or anemia, while urinalysis and culture can identify urinary tract infections that might present with similar symptoms. A pregnancy test is essential despite the IUD to rule out pregnancy, including ectopic pregnancy which would require immediate intervention. During the physical exam, it is crucial to assess for IUD strings, evaluate for signs of pelvic organ prolapse, and check for tenderness or masses that might explain the pressure sensation. This comprehensive approach will help determine if the IUD is causing the symptoms or if another gynecological condition is responsible. Key points to consider in the workup and exam include:

• Ordering a pelvic ultrasound (transvaginal and transabdominal) to confirm IUD placement
• Performing basic laboratory tests including CBC, urinalysis, urine culture, and pregnancy test (serum hCG)
• Assessing for IUD strings and evaluating for signs of pelvic organ prolapse during the physical exam
• Checking for tenderness or masses that might explain the pressure sensation
• Considering the patient's individual needs and risk for discontinuation when developing a plan for follow-up.

From the Research

Initial Assessment

• The patient is experiencing vaginal pressure with an IUD in place, but no bleeding or discharge is reported.
• A thorough medical history and physical examination, including a bimanual examination, are necessary to assess the patient's condition 2.

Ultrasound Evaluation

• Ultrasonography is the first-line imaging modality for evaluating IUD position, especially in patients with pelvic pain or absent retrieval strings 3, 4.
• A transvaginal or transabdominal ultrasound can be ordered to assess the position of the IUD and rule out any malposition, expulsion, or perforation.

Laboratory Tests

• There is no indication for routine laboratory tests, such as sexually transmitted infection (STI) testing, in this scenario, as the patient is not presenting with symptoms of an STI and is already using an IUD for contraception 5.
• However, if the patient's symptoms persist or worsen, further evaluation and testing may be necessary to rule out other underlying conditions.

Management Considerations

• If the IUD is found to be malpositioned or expelled, management considerations will depend on the severity of the malposition and the presence or absence of symptoms 3, 4.
• The patient's symptoms and medical history will guide further management and treatment.