How should pyometra be managed in a patient with an intrauterine device (IUD) left in situ?

Management of Pyometra with IUD In Situ

Initiate broad-spectrum antibiotics immediately and the IUD does not need to be removed right away if the patient desires ongoing contraception. 1

Initial Management Algorithm

Step 1: Start Antibiotic Therapy

• Begin appropriate broad-spectrum antibiotics according to CDC STD Treatment Guidelines for pelvic inflammatory disease (PID), as pyometra in the setting of an IUD is managed similarly to PID 1
• Provide comprehensive management including counseling about condom use 1

Step 2: Decision About IUD Removal

The IUD can remain in place initially while antibiotics are started 1

• Evidence shows treatment outcomes do not generally differ between women with PID who retain the IUD versus those who have it removed 1
• One randomized trial demonstrated women with IUDs removed had longer hospitalizations than those who retained the device, with no differences in PID recurrences or subsequent pregnancies 1
• Another randomized trial showed no differences in laboratory findings between IUD removal versus retention 1

Step 3: Mandatory Reassessment at 24-48 Hours

Reassess the patient within 24-48 hours of initiating antibiotics 1

• If clinical improvement occurs: Continue antibiotics and the IUD may remain in place 1
• If no clinical improvement occurs: Continue antibiotics AND consider removal of the IUD 1

IUD Removal Technique (When Indicated)

Timing of Removal

• Remove the IUD after antibiotics have been started, not before, to avoid potential risk for bacterial spread resulting from the removal procedure 1

Removal Method

• Locate the IUD strings during speculum examination 2
• Remove the device by pulling gently on the strings 2
• If strings are not visible, perform or refer for ultrasound examination to determine IUD location 2

Post-Removal Management

• Consider emergency contraceptive pills (ECPs) if appropriate 1
• Counsel on alternative contraceptive methods and offer another method immediately if desired 1, 2
• Advise the patient to return promptly if she experiences heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever 1, 2

Critical Pitfalls to Avoid

Do Not Remove IUD Before Starting Antibiotics

• Removal before antibiotic initiation risks bacterial dissemination 2
• Always time removal after antibiotic therapy has begun 2

Do Not Attempt Forceful Removal

• Never attempt forceful removal if strings are not visible, as this risks uterine perforation 2
• Use ultrasound guidance when strings cannot be located 2

Do Not Assume Immediate Removal Is Necessary

• The evidence base from multiple randomized trials supports that immediate removal is not required and may actually prolong hospitalization 1
• Close clinical follow-up with reassessment at 24-48 hours is the key to determining whether removal becomes necessary 1

Evidence Quality Note

The CDC guidelines are based on a systematic review of four studies including randomized trials (Level of evidence: I to II-2, fair, direct) 1. While no specific evidence exists for LNG-IUDs in this context, the management principles apply to both copper and levonorgestrel-releasing IUDs 1.