O.O Bello1, O.O Ayandipo2, and R.O Olayide1
- Department of Obstetrics and Gynecology, University College Hospital, Ibadan, Nigeria
- Department of Surgery, College of Medicine, University of Ibadan/University College Hospital, Nigeria.
A Copper T intrauterine contraceptive device (IUCD) is a commonly employed method of reversible contraception for women. Its use has been associated with complications such as bleeding, perforation and migration to adjacent organs or peritoneum. Uterine wall erosion and subsequent perforation by an IUCD is not unusual; however the subsequent intraperitoneal migration, to and perforation of the rectum is uncommon. We present a case of 31-year-old female with an IUCD migrating through the uterus possibly into the peritoneal cavity and subsequently eroding into the posterior rectal wall. It was removed easily without complications through the rectum during an examination under anesthesia.
Keywords: Intrauterine contraceptive device, perforation, migration, rectum.
Dr. O.O. Bello
Dept. of Obstetrics and Gynecology,
University College Hospital,
Intrauterine contraception as a form of contraception is a popular choice amongst women seeking long-term pregnancy prevention. The intrauterine contraceptive devices (IUCDs) are safe and highly effective reversible contraceptives that are also economical1,2. Complications like displacement, embedment, expulsion and perforation are often associated with malpositioning of IUCD but mishaps can also occur despite proper placement and positioning3-6. About 18% of IUCD users may experience expulsion and missing strings, however uterine erosion/ perforation is an uncommon, but serious, complication3. Perforation may be asymptomatic or symptomatic. There could be varying symptoms like abdominal pain, chronic pelvic pain, abnormal vaginal or rectal bleeding, irritative lower urinary tract symptoms, bowel or bladder perforation, peritonitis, unwanted pregnancy, intestinal obstruction, abscess or fistula formation depending on the organ of penetration and the interval from the time of penetration and patient’s response3- 5. Here, we report a case of an IUCD migrating through the uterus into the peritoneal cavity and uninterruptedly into the rectum.
Mrs. A.O a 31-year-old Para 2+0 (2 Alive) woman had an uncomplicated IUCD (Copper-T 380A) inserted and subsequently, could not feel the strings within 1 week of its insertion. There was no history of abdominal pain or abnormal vaginal or rectal bleeding. However, she did not present in the hospital despite the pre and post insertion counseling given to her. Three months after the IUCD insertion she missed her period. Ultrasound done confirmed a 9weeks live gestation and showed a displaced IUCD in the uterine wall. She was counseled on the complications of pregnancy with IUCD in-situ and it was planned for removal after delivery. Pregnancy was otherwise uneventful until late third trimester when she had premature labour and delivery of a live male neonate at 35 weeks gestational age. She did not present in the hospital after delivery as scheduled because of the fear of surgery until 3 months postpartum when she noticed the IUCD strings protruding from her anus (Fig. 1)
There was no accompanying abdominal pain, change in her bowel habit (constipation, diarrhoea), hematochezia, anal pain or swelling. During the pelvic examination, about 4cm length of the IUCD strings was visible at the anal orifice. Pelvic ultrasonography showed a morphologically normal sized uterus with the IUCD located outside the uterus, possibly in the rectum. An abdominal X-ray confirmed the presence of the IUCD in the pelvis posterior to the uterus (Fig.2). The patient was counseled on the need to undergo an examination under anaesthesia with removal of IUCD. She had rectal washouts and an informed consent was obtained. The procedure was planned along with the general surgeons. At examination, the T-junction of the IUCD was found embedded in the posterior rectal wall about 4cm from the anal verge (Fig. 3). The IUCD was removed under direct vision, by slightly pulling on the strings, after digital prolapse of the rectum. There was a pin-hole dimple after removal that was not bleeding. The patient had a smooth postoperative recovery. She opted for a contraceptive implant in view of her desire to space her children and plan her family size.