Contraception 91 (2015) 261 – 263

Case report

Rectal perforation with an intrauterine device: a case report☆ Courtney Eichengreen, Haley Landwehr 1 , Lisa Goldthwaite⁎, Kristina Tocce University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO 80045, USA Received 14 November 2014; revised 6 December 2014; accepted 8 December 2014

Abstract A 27-year-old woman presented for routine examination 1 year after intrauterine device (IUD) placement; strings were not visualized. The device was found to be penetrating through the rectal mucosa. It was removed easily through the rectum during an examination under anesthesia. Perforated IUDs with rectal involvement require thoughtful surgical planning to optimize outcomes. © 2015 Elsevier Inc. All rights reserved. Keywords: Complications; Intrauterine device; Perforation; Rectum

1. Introduction Contraceptive intrauterine devices (IUDs) are safe, reversible and highly effective. In the United States, IUD use has increased from 0.8% in 1995 to 5.6% in 2006–2010 [1]. This trend is likely to continue since the World Health Organization (WHO) and the American College of Obstetricians and Gynecologists have endorsed IUDs as first-line contraception [2]. A relatively rare, but serious, complication of IUD insertion is uterine perforation [3,4]. Physicians can expect to see more cases of perforation as the use of IUDs increase. When the perforated IUD is in the abdomen, laparoscopic removal is standard of care [5]. We present a patient found to have a copper IUD perforating the rectal mucosa below the peritoneal fold, requiring an alternative approach for removal. 2. Case A 27-year-old gravida 2, para 1011 had a copper T380A IUD placed by a certified nurse midwife (CNM) at a 6-week postpartum visit. She next presented to the University ☆

Financial support: The authors have no funding sources to report. ⁎ Corresponding author at: Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, 12631 E. 17th Avenue, Box B-198-2, Aurora, CO 80045, USA. E-mail address: [email protected] (L. Goldthwaite). 1 Wake Forest School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157, USA. http://dx.doi.org/10.1016/j.contraception.2014.12.004 0010-7824/© 2015 Elsevier Inc. All rights reserved.

Midwifery Clinic for her well-woman exam 1 year later. On speculum exam, the IUD strings were not visualized. The patient had never tried to feel the strings and had not seen the IUD expulse. She was well appearing and without complaints. A pelvic ultrasound showed an empty uterine cavity. Abdominal x-ray confirmed the presence of the IUD in the pelvis (Fig. 1); the radiologist recommended further evaluation by computed tomographic (CT) scan or laparoscopy. The CNM simultaneously ordered a CT scan and consulted the gynecology service for laparoscopic IUD removal. When the CT revealed the shaft of the IUD within the rectouterine space with one arm extending into the lumen of the rectum (Figs. 2 and 3), the patient was referred to the Family Planning service for evaluation. The IUD arm was easily palpable 4 cm from the anus at the time of her preoperative rectal exam. The general surgery service was consulted, and a collaborative decision was made to attempt direct rectal removal of the device during an exam under anesthesia (EUA). In the operating room, a Hill Ferguson retractor was used to visualize the rectal vault and the arm of the IUD (Fig. 4). The protruding arm was grasped with ring forceps, and the entire IUD was easily removed intact. Immediate sigmoidoscopy showed a minimal defect in the rectal wall, without evidence of fistula or abscess (Fig. 5). Repair of the mucosa and further interventions were not necessary. On postoperative day 1, the patient returned to clinic and was doing well; she elected to begin progesterone-only pills for contraception. After 2 years of uneventful follow-up, the patient had an intended and uncomplicated pregnancy. The

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Fig. 3. Axial plane of pelvic CT with contrast, showing the IUD in the rectouterine space with one arm protruding into the bowel lumen.

Fig. 1. Abdominal x-ray of the IUD in the lower abdomen.

patient has provided written consent for the publication of this case report. 3. Comment The sequelae of uterine perforation and extrauterine IUDs can be severe, including bowel obstruction, bowel perforation, peritoneal abscess, fistula formation and unintended pregnancy [3,5]. Primary symptoms of perforation may include pain at time of insertion, delayed abdominal or pelvic pain and irregular vaginal bleeding [5–7]. However, many women with extrauterine IUDs are asymptomatic and few cases are recognized at the time of the IUD insertion [6]. The WHO recommends prompt removal of all displaced IUDs once recognized, and laparoscopy is the preferred surgical technique [3,5]. Our case is unusual in that the

Fig. 2. Coronal plane of pelvic CT with contrast, showing the IUD in the rectouterine space with one arm protruding into the bowel lumen.

perforated IUD was below the peritoneal fold, which was not evident on abdominal x-ray (Fig. 1). Standard laparoscopy would not have been effective. Seven cases of perforated IUDs with rectal involvement have been previously described; of these, six presented with symptoms of pain, bleeding, changes in bowel habits or strings at the anus [8–13]. Our case illustrates that an IUD penetrating the rectal mucosa can also present insidiously. One case without rectal symptoms was described previously, but the rectal IUD was only found after laparoscopy [14]. Recognition of an extraperitoneal IUD allows for advanced planning of an effective, and potentially noninvasive, removal approach. Preoperative diagnosis of an IUD in this unusual location may not always be possible, as CT scans are not routinely ordered. A rectal exam can be considered during the preoperative evaluation as an intervention that may significantly influence the surgical approach if an IUD is palpated. Similarly, in cases where an IUD is not found during laparoscopy, an extraperitoneal location must be considered. In such cases of rectal perforation below the peritoneal fold, removal with EUA can minimize both local trauma and surgical risk.

Fig. 4. Direct visualization of an arm of the IUD in the rectal vault prior to attempted removal.

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Fig. 5. Immediate postoperative sigmoidoscopy showing minimal defect in rectal wall after removal.

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