An intrauterine device (IUD) is a small, T-shaped contraceptive placed inside the uterus by a healthcare provider. It is a highly effective, long-acting, and reversible form of birth control. Uterine perforation is a rare but serious complication that occurs when the IUD breaches the uterine wall. This complication requires immediate clinical evaluation because it can lead to injury to nearby organs if the device migrates into the abdominal cavity. The question of whether an IUD perforation constitutes an emergency depends on the type of perforation and the patient’s symptoms, but it always warrants urgent medical attention.
Understanding IUD Perforation and Urgency
IUD perforation is generally estimated to occur in less than 1 in 1,000 insertions. However, it is considered a serious medical event because the device has exited its intended space. The perforation is most likely to happen at the time of insertion, particularly if the provider inserts the device within six weeks postpartum or while the patient is breastfeeding.
Perforations are classified into two main types: partial and complete. A partial perforation means the IUD has embedded itself into the muscular wall of the uterus, known as the myometrium, but has not fully passed through it. In a complete perforation, the device has passed entirely through the uterine wall and may have migrated into the peritoneal cavity, the space within the abdomen containing the bowel and other organs.
A partial perforation may remain stable, but uterine contractions can sometimes cause it to progress to a complete perforation days or months later. Once completely outside the uterus, the IUD can migrate and potentially cause damage to structures like the bowel or bladder. A perforated IUD is a medically urgent situation that requires prompt localization and management to prevent complications.
Recognizing the Warning Signs
Recognizing the warning signs is challenging because many patients with a perforated IUD are initially asymptomatic; some studies suggest up to 43% of cases have no symptoms at the time of diagnosis. For those who do experience symptoms, the most frequent initial indicator is the inability to feel the IUD strings. This suggests the device may have expelled or migrated entirely out of the uterus.
Patients may experience severe, persistent abdominal or pelvic pain that feels different from normal menstrual cramping, especially in the days or weeks immediately following insertion. Pain during sexual intercourse, or dyspareunia, can also be a sign that the device is not correctly positioned. Abnormal vaginal bleeding or spotting that is prolonged or significantly heavier than usual should also be noted.
If the IUD has migrated into the abdominal cavity and caused an infection or injury to other organs, symptoms can become more severe. Signs of a serious complication include fever and chills, which suggest a potential infection like peritonitis. In rare cases of bowel perforation, symptoms such as diarrhea, rectal bleeding, or signs of an intestinal obstruction may occur.
Immediate Steps If Perforation is Suspected
If you suspect IUD perforation because you cannot feel the strings or are experiencing unusual pain, you should contact your healthcare provider immediately. It is important to treat this situation with urgency, even if your symptoms are mild, because the device’s location needs to be confirmed. Providers often advise going to an emergency room or an urgent care facility if your regular clinic is closed or cannot see you promptly.
You should avoid attempting to adjust, pull, or remove the IUD yourself, as this could cause further injury if the device is partially embedded. When speaking with medical staff, be sure to clearly state that you have an IUD and that you suspect a complication, mentioning when the device was inserted. Providing a detailed account of the onset, nature, and severity of your symptoms will help the medical team prioritize your evaluation.
It is also advisable to use a backup method of contraception immediately, as a perforated IUD is no longer effective at preventing pregnancy. Be prepared to answer questions about any recent changes, such as whether you have recently given birth or are breastfeeding, as these factors can increase the risk of perforation. The priority is to confirm the IUD’s location and ensure your immediate safety before any treatment decisions are made.
Medical Diagnosis and Management
Once you arrive for medical care, the diagnostic process typically begins with a physical examination to check for the presence of the IUD strings. If the strings are not visible, the next step is usually a transvaginal ultrasound, which is the primary tool for determining the IUD’s location within the pelvic area. The ultrasound can confirm if the IUD is still in the uterus, partially embedded in the myometrium, or if it is entirely outside the uterus.
If the IUD cannot be seen on the ultrasound, an X-ray or a CT scan of the abdomen and pelvis is performed to locate the device, as most IUDs contain materials visible on these imaging techniques. Once the IUD’s exact location and position are confirmed, a management plan is developed, which almost always involves removal to prevent long-term complications such as adhesion formation or organ damage.
If the IUD is only partially embedded in the uterine wall, it may be removed via hysteroscopy, a minimally invasive procedure where a small camera is inserted through the cervix. However, if the device has completely migrated into the abdominal cavity, its removal usually requires laparoscopic surgery. Laparoscopy involves small incisions through which instruments are passed to safely retrieve the IUD from the peritoneal cavity, minimizing the risk of injury to surrounding organs.
In very rare and complex cases, such as when the IUD has caused significant organ damage or is heavily adhered to tissue, a more extensive surgery called a laparotomy may be necessary. Following the removal, follow-up care is provided, which includes counseling on alternative contraceptive methods and monitoring for any remaining signs of infection or organ injury.