Uterine perforation and embedding by intrauterine device: evaluation by US and hysterography.

Uterine perforation and deep embedding by an intrauterine device (IUD) require exact determination of its location as a necessary step to safe and effective retrieval. Six cases of uterine perforation and four of embedding by an IUD were studied with ultrasonography (US) and hysterography. While US findings suggested the correct diagnosis of perforation in five of the six cases, hysterography yielded more exact diagnostic information. Deep embedding could only be diagnosed with hysterography. A classification of the types of perforation and an algorithm for diagnosing ectopic IUD are presented. Undue reliance on the sonographic appearance of an IUD in the center of the uterine image may lead to hazardous attempts at transvaginal removal of a device that is partly intramural. In this study, hysterography offered the most precise diagnostic information.

Satisfaction with body image for early adolescent females: The impact of pubertal timing within different school environments.

During adolescence dramatic physical changes take place which the individual must incorporate into his or her evolving body image. The impact of different school environments on this incorporation process is explored using data on 225 White females from a longitudinal study. Differences in physical characteristics between early, middle, and late developers were assessed each year. The effects of pubertal timing on satisfaction with body image dimensions and self-esteem were then explored for sixth- and seventh-graders within different school environments. Reference group theory was used to examine three alternative hypotheses. Early versus late onset of menarche had different effects on certain aspects of satisfaction with body image, depending on the school environment. Results support the strength of the cultural ideal of thinness for women, but no other hypothesis had consistent support. The findings indicated the need to consider a multiplicity of factors in relation to specific body image dimensions.

Perforation of the bladder by the intrauterine device.

PIP: Probably because of its rarity, the IUD complication of bladder perforation has seldom been diagnosed prior to intervention. This article presents in tabular form data on 8 cases of bladder perforation by IUDs in an effort to develop appropriate methods of preoperative diagnosis. Several types of bladder perforation were found in the 8 cases. The main symptom was recurrent and persistent cystitis which usually responded only temporarily to therapy. Symptoms included dysuria, burning on urination, frequency, nocturia, occasional hematuria, lower abdominal and suprapubic pain, and bladder pressure. Objective evidence was provided by microscopic pyuria and hematuria, as well as positive urine cultures. In most cases, symptoms appeared soon after insertion or within a few months. Attacks of cystitis starting shortly after insertion of the IUD and continuing repetitively should arouse suspicion of bladder perforation, and concomitant absence of the IUD string or unanticipated pregnancy should heighten the suspicion. Preliminary investigation prior to cystoscopy is preferrable beginning with a plain X-ray film in anteroposterior (AP) and lateral projections. If a bladder calculus has not formed or is insufficiently radiopaque, the AP film can be misleading unless a lateral film is also taken. Although it was used in only 2 cases, sonography will probably prove increasingly valuable in the diagnosis of bladder perforations by IUDs. If sonography does not demonstrate the intravesical IUD, opacification of the bladder by intravenous pyelography or retrograde cystography, using AP and lateral films, may show it. Hysterography may be helpful when sonography or intravenous pyelography or retrograde cystography give a hint of concomitant partial uterine location of the IUD. Cystography after preliminary tests can help in planning the optimal approach for removing the IUD. In the 8 cases the free-floating IUD was removed by cystoscopy in 3 cases, the adherent IUD by suprapubic cystotomy in 4 cases, and by vaginal cystotomy in 1 case. In general, suprapubic cystotomy is the procedure of choice for removing an IUD perforating into and adherent to the bladder wall.^ieng

Physical attractiveness as a mediator of the impact of early pubertal changes for girls.

The present study examined the effects of early pubertal development and physical attractiveness on the popularity, body image, and self-esteem of over 200 sixth-grade girls. Two rival hypotheses were explored. The first suggests that physically attractive girls, because of their more favorable social environment, will exhibit fewer psychosocial difficulties than unattractive girls during pubertal development. The second hypothesis argues that attractive girls will exhibit greater difficulty during pubertal transition because their self-image is more intimately connected with their physical appearance. Although there were no significant interactions between attractiveness and pubertal development for either popularity or body image, the second hypothesis was supported with respect to self-esteem. Specifically, developing attractive girls exhibited lower self-esteem than their unattractive counterparts. The results are discussed in terms of the relative vulnerability to bodily changes of girls differing in physical attractiveness.

Complete and partial uterine perforation and embedding following insertion of intrauterine devices. II. Diagnostic methods, prevention, and management.

PIP: This paper discusses the various methods used to diagnose uterine perforation caused by an IUD. Radiography, or plain film, has a limited use in the diagnosis of uterine perforation since its usefulness depends on the radiopacity of the particular IUD; if the IUD appears on film, plain film does not allow one to conclude whether the device is in its proper position. Several modifications of plain film have been tried but all methods fall short of their goals. Hysterography permits the best diagnostic assessment since it allows the visualization of the entire uterine cavity so that the position of the IUD is immediately evident in cases of embedding and of perforation. Pelvic pneumography can differentiate between intraperitoneal or extraperitoneal locations of perforated IUDs; it can be enhanced by hysterosalpingography and can be done on an ambulatory basis. Ultrasonography simply determines the presence or absence of an IUD, but has the advantage of accurately demonstrating a concomitant pregnancy; the sonogram is not reliable if the IUD is surrounded by omentum or by loops of bowel; ultrasonography can be advantageously coupled with hysterography. Laparoscopy is still the method most used to diagnose uterine IUD perforation; when removal of the device is advisable laparotomy is usually carried out concomitantly; successful laparoscopy requires a skilled and experienced operator. Hysteroscopy is a new and extremely valuable technique which should not be chosen as a primary procedure because it carries a risk of complications. The best prevention of uterine perforation is a meticulous and well executed insertion technique, done only by an experienced operator and after a careful pelvic examination. Uterine size, consistency and position must be exactly known; IUD insertion is easier during or immediately after menstruation. Perforated IUDs should be removed even if considered innocuous, although this is a matter still debated by the specialists. Spontaneous IUD expulsion must be verified, when not proven, by the same methods used by perforation diagnosis, or by dilatation and curettage. Before deciding on the best method for removal it is necessary to know the type of perforation and the location of the ectopic IUD. Removal of an IUD, whether through the vagina or through hysteroscopic, laparoscopic, laparotomy, or hysterotomy procedures, is never easy. Emergency hysterectomy is done under certain circumstances, such as hemorrhage, while elective hysterectomy requires the presence of additional factors, such as a fibroid uterus. Colpotomy is done only when the IUD is lying in the posterior cul-de-sac.^ieng

Complete and partial uterine perforation and embedding following insertion of intrauterine devices. I. Classification, complications, mechanism, incidence, and missing string.

PIP: This report of complete and partial uterine perforation and embedding following IUD insertion is based on a review of the pertinent literature of the past 15 years. An analysis of 356 cases reported in the literature during this time are included. A classification is proposed based on the distinction between complete and partial perforation. Of all perforations of the uterus, be they fundal, lower segmental, or upper cervical, the completely perforated IUD is the type most often encountered, most commonly described, most readily recognized, and most easily removed. To differentiate between perforated IUDs, 3 anatomical compartments are postulated. For the purposes of discussion, the endometrial and serosal layers of the uterus are disregarded, leaving only the myometrium as its truly essential feature. Compartment 1 is the uterine cavity; compartment 2, the myometrium; and compartment 3, the peritoneal cavity. Completely perforated and, less often, partially perforated IUDs may intrude upon neighboring viscera, particularly the intestinal tract, resulting frequently in seriously ill patients who require intensive treatment including intestinal surgery. In the review of 356 case reports, such special situations arose in 53 cases, or 15%. Of the 53 reported cases, 41 concerned the intestinal tract. There were 6 cases in which the IUD was in the bladder. In 1 case, the perforation had been partial (Lippes loop) and, in 5 cases, complete (4 Lippes loop and 1 Dalkon shield). There were 3 cases in which the uterus was involved under special circumstances. There were 5 cases in which death occurred in relation to uterine perforation by IUD. It is probable that, of the various factors responsible for uterine perforation by IUDs, the most important are the consistency and flexion of the uterus, the type and the rigidity of the IUD and its inserter, and the amount of force exerted at insertion, with the result that the IUD stops at a certain point rather than proceeding to complete perforation. If the IUD does not penetrate beyond the uterine wall, i.e., if it is type 1-2 or type-2 perforation, negative intraabdominal pressure does not obtain. If the IUD had penetrated beyond the uterine wall, the theoretical possibility exists for further progression to type 3 perforation more readily than in the type 1-2 or type 2 perforation. In this review of 356 cases, 352 cases were suitable for analysis. Of these there were 53 unusual complications involving the intestinal tract, bladder, and so forth. There were 299 cases of simple perforation involving the uterus only, of which 255 were complete and 44 were partial. The mechanism of cervical perforation appears to depend on the presence of an IUD with a dependent limb in its design. Embedding, diagnosis, and the problem of the missing string are reviewed.^ieng