Initial Imaging for Suspected IUD Bladder Perforation
Order retrograde cystography (either conventional radiography or CT cystography) as the diagnostic procedure of choice when an IUD is suspected to have perforated the bladder. 1
Primary Diagnostic Approach
Retrograde cystography is the gold standard for detecting bladder injuries and should always be performed in hemodynamically stable patients with suspected bladder perforation. 1 This applies directly to IUD perforation scenarios, as the IUD represents a penetrating mechanism that may have violated bladder integrity.
CT Cystography vs. Conventional Cystography
CT cystography is preferred over conventional cystography when available, as it provides equivalent diagnostic accuracy (95-100% sensitivity and specificity) while allowing comprehensive evaluation of surrounding structures and the IUD position. 2, 3, 4
The technique requires retrograde distention of the bladder with dilute iodinated contrast material through a urethral catheter, followed by CT imaging of the pelvis with a contrast-filled bladder. 2, 3, 4
Passive filling through IV contrast with a clamped catheter is inadequate and results in high false-negative rates due to insufficient intravesical pressure. 1
Post-void images may provide additional information, though some evidence suggests they may be unnecessary in certain cases. 1
Important Caveats and Pitfalls
What NOT to Order Initially
Contrast-enhanced CT with delayed urographic phase alone is less sensitive and specific than retrograde cystography for detecting bladder injuries. 1 While this modality is excellent for kidney and ureteral injuries, it is insufficient for bladder evaluation.
Ultrasound is not appropriate for initial evaluation of suspected bladder perforation, as it lacks the sensitivity to reliably detect bladder wall injuries. 1
Clinical Indicators Requiring Imaging
Suspect IUD bladder perforation and proceed with cystography if the patient presents with: 1
- Gross hematuria (macroscopic blood in urine)
- Suprapubic tenderness or pain
- Inability to void or low urine output
- Recurrent urinary tract infections
- Pelvic pain with known IUD placement
- IUD strings not visible on speculum examination with concern for migration
Technical Considerations
If urethral injury is suspected (blood at urethral meatus, recent trauma), perform retrograde urethrography before bladder catheterization to avoid worsening urethral disruption. 1, 5
Multiplanar reformatted images on CT cystography improve diagnostic accuracy, particularly for posterior wall injuries that may be missed on conventional lateral views. 1, 3
The bladder must be adequately distended (typically 300-400 mL of dilute contrast) to detect subtle perforations. 3, 4
Additional Imaging to Localize the IUD
Once bladder injury is confirmed or excluded, non-contrast CT of the abdomen and pelvis can precisely localize a malpositioned or perforated IUD, as these devices are radiopaque and easily visualized. 6
This helps surgical planning by determining whether the IUD has migrated into the peritoneal cavity, bladder wall, or other pelvic structures. 6