Lost IUD penetrating bladder wall.

Thanks to Vural and colleagues who reported their interesting case of a misplaced intrauterine device (IUD).1 I would like to mention some points in relation to their letter. With the increased uptake of intrauterine methods2 and the majority of uterine perforations said to occur at the time of device insertion (but go undetected),3 uterine perforation is more frequent than Vural et al.1 suggest. Uterine perforation is now undiagnosed at the time of IUD insertion procedure, also because patients are asymptomatic despite this complication having occurred. There is currently greater use of analgesia prior to as well as local anaesthetic (including injectable) during IUD insertion procedures than before. To facilitate early diagnosis of uterine perforation, especially in the absence of symptoms, clinicians should have a low threshold for performing, or referring for, pelvic ultrasonography. Instances of difficult insertion, insertion after difficult removal, where uterine sounding measurements are much different from the previous of a patient’s (especially after a difficult removal of an old device), and no visible threads at routine follow up post-IUD insertion are examples. Unfortunately most services where IUD fitting procedures take place are not equipped with ultrasound scanners. Where there is local access to ultrasound or a referral has to be made, appointment waiting times tend to cause a delay in diagnosis of uterine perforation. Similarly, an appointment for laparascopic removal of a misplaced device could be a few months. However, initial counselling on intrauterine methods4 to include information about the small risk of uterine perforation and its management will be helpful to patients interested in this highly effective method of contraception.