Hidden in plain sight: A malpositioned intrauterine device as the culprit of acute pelvic pain - a case report

Malpositioned intrauterine devices (IUDs) are not yet a well recognized cause of acute pelvic pain. Correct identification relies on recognizing key imaging findings such as low-lying or endocervical positioning, and an understanding that acute pelvic pain may be the result of a malpositioned IUD. We report the case of a 28-year-old sexually active female (she/her/hers) with a history of a malpositioned IUD, who presented with sudden onset, unprovoked, right sided pelvic pain. She denied hematuria, dysuria, vaginal discharge, or vaginal bleeding. On physical examination she noted right-sided pelvic tenderness below McBurney's point; however, a pelvic examination was deferred. Ultrasound revealed an IUD in the endocervical canal. A CT confirmed a low-lying IUD. These findings were initially interpreted as normal. Only after follow-up with primary care, the IUD was removed and the patient reported complete resolution of her symptoms. This case highlights the importance of recognizing malpositioned IUDs on imaging. As in this case, misdiagnosis can result in overtesting and delays in patient care. Emergency providers should be familiar with radiographic findings and include malpositioned IUDs on their differential diagnosis.