Should a 6-year-old female patient with a Mirena (levonorgestrel-releasing intrauterine device (IUD)) presenting with new-onset bleeding and radiating lower back pain go to urgent care or the Emergency Department (ED)?

Emergency Department Evaluation Required

This clinical scenario is medically impossible and requires immediate Emergency Department evaluation to clarify the actual situation, as a 6-year-old child cannot have a Mirena IUD.

Critical Clinical Impossibility

• Mirena IUDs are only approved for use in women of reproductive age and are never placed in prepubertal children 1, 2
• The presence of a Mirena IUD in a 6-year-old represents either a critical documentation error, potential abuse situation, or medical device misidentification that requires urgent investigation 1

Why This Requires Emergency Department Care

Immediate Safety Concerns

• New-onset bleeding and radiating lower back pain in any 6-year-old child warrants emergency evaluation regardless of the IUD question, as these symptoms could indicate:
  • Serious intra-abdominal pathology
  • Urinary tract infection with pyelonephritis
  • Renal calculi
  • Trauma (accidental or non-accidental)
  • Other acute surgical conditions 1

Required Emergency Evaluation

• Urgent pelvic/abdominal imaging is needed to identify any foreign body and assess for the source of bleeding and pain 1
• Comprehensive physical examination must be performed in a controlled ED setting with appropriate pediatric expertise and potential child protective services involvement if indicated 1
• Laboratory evaluation including complete blood count, urinalysis, and pregnancy test (despite age) is necessary to evaluate bleeding and rule out other pathology 1

Clinical Decision Algorithm

Go to Emergency Department immediately if:

• Patient is actually a child (age <10 years) with any IUD-related concern
• New-onset severe back or pelvic pain in any patient with an IUD 1
• Bleeding with pain that could represent ectopic pregnancy, device perforation, or other serious complications 1
• Any concern for device migration or perforation (suggested by radiating back pain) 3

Critical Red Flags Requiring ED Evaluation

• Radiating lower back pain with an IUD can indicate device perforation or migration into adjacent structures including bladder or bowel 3
• New-onset bleeding with pain requires exclusion of pregnancy (including ectopic), infection, or device displacement 1
• Urgent care facilities lack the imaging capabilities and specialist consultation needed for potential IUD complications in this age group 1