MILITARY MEDICINE, 179, 1:e127, 2014

Sigmoid Colon Penetration by an Intrauterine Device: A Case Report and Literature Review Hideo Takahashi, MD; LCDR Krista M. Puttler, MC USN; CDR Cheuk Hong, MC USN; LCDR Alexander L. Ayzengart, MC USN ABSTRACT Background: The intrauterine device (IUD) is one of the most effective contraceptive methods available today. However, IUDs can cause some serious complications, such as bleeding, uterine perforation, and bowel perforation. Migration into bowel is a rare but serious complication that requires surgical attention. Case: A 35-year-old multiparous female was diagnosed with IUD migration into the abdominal cavity. Upon diagnostic laparoscopy by gynecologic surgeons, sigmoid colon penetration by the IUD was strongly suspected. After confirmation of the penetration by abdominal computed tomography scan with oral/rectal and intravenous contrast and colonoscopy, she underwent sigmoid colon resection to retrieve the IUD without complications. Conclusion: The symptoms of IUD migration can be nonspecific, requiring a high degree of suspicion. Also, cross-sectional imaging studies are recommended to rule out adjacent organ involvement if IUD migration is suspected.

INTRODUCTION The intrauterine device (IUD) is one of the most effective measures of contraception available today with its use increasing yearly. However, IUDs have been associated with serious complications such as bleeding, uterine perforation, and bowel perforation. Migration into bowel is a rare but serious complication that requires surgical attention. We present one rare case of an asymptomatic IUD penetration into the sigmoid colon along with the literature review. CASE A 35-year-old multiparous female underwent copper IUD (ParaGard) insertion 2 months after her second child was born when she was 29 years old. The insertion was uneventful. Three months after the insertion, she had excruciating abdominal pain accompanied with vaginal bleeding upon which she visited an emergency department. The IUD was not seen on vaginal examination nor was it seen on transvaginal ultrasound. The transvaginal ultrasound showed no intra-abdominal fluid or inflammation adjacent to the uterus, and she was told that the IUD had fallen out. She did not undergo further radiographic evaluation at that time. Subsequently, she became pregnant and had her third child via spontaneous vaginal delivery. Following this pregnancy, she underwent abdominoplasty, umbilical hernia repair, and Essure tubal occlusion, a permanent, nonsurgical transcervical sterilization procedure.1 No IUD was seen in the uterus during the Essure procedure. Confirmatory hysterDepartment of General Surgery, U.S. Naval Hospital Yokosuka, Japan, 1 Tomari, Yokosuka Kanagawa 238-0001, Japan. The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. doi: 10.7205/MILMED-D-13-00268

osalpingography showed that the IUD was located outside the uterine cavity but did not show extravasations of the contrast. As she was completely asymptomatic at that time, she did not seek further evaluation. Two years later, she elected to have the misplaced IUD removed and was evaluated by the gynecological surgery department in our hospital. She denied abdominal pain, change in bowel habits, bright red blood per rectum, melena, decrease caliber of stool, vaginal bleeding, vaginal discharge, dyspareunia, dysuria, or hematuria. She was taken to the operating room and underwent a diagnostic laparoscopy. The IUD appeared to be closely adhered to the wall of the sigmoid colon (Fig. 1). Because of the possibility of IUD penetration into the sigmoid colon and the absence of consent for a possible bowel resection, the laparoscopy was terminated to allow for further evaluation with abdominal and pelvic computed tomography (CT) scans and colonoscopy. CT scans with intravenous and oral/rectal contrast showed a possible penetration of the sigmoid colon without any evidence of bowel obstruction, mesenteric inflammation, or free intraperitoneal extravasation of contrast. IUD penetration into the lumen of the sigmoid colon was confirmed on colonoscopy (Fig. 2). She proceeded to the operating room for IUD removal and sigmoid colon resection the following day. The skin incision was made along the previous Pfannenstiel scar. The uterus was retroverted and slightly enlarged, but otherwise normal. The IUD was embedded within the surrounding adipose tissue of the sigmoid colon approximately 3 cm superior to the rectosigmoid junction. The sigmoid colon was resected with the IUD in place. And the anastomosis was performed using a 28-mm end to end anastomotic stapler. The pathology report showed that the IUD perforated through the entire bowel wall from the serosa to the mucosa. The patient’s operative and postoperative course was unremarkable and she was discharged to home on postoperative day 5 without complications.

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FIGURE 1. Initial laparoscopic findings. This is a view looking toward pelvis. There are dense adhesions (black triangle) between the uterus (white arrow) and the sigmoid colon (black arrow). The majority of the IUD was not visible in this adhesion. One tip of the IUD (black triangle) and the IUD string (white triangle) are visible.

DISCUSSION The IUD is one of the most effective contraceptive methods of today. It is nearly 99% effective, long-acting, as well as rapidly reversible. The use of IUDs has been increasing worldwide. For example, according to the World Health Organization, the rate of women who use IUD as a contraceptive method in the world was 14.3% in 2009. In the United States, the rate was 5% in 2006–2008 whereas it was 2% in 2002.2 Uterine perforation after insertion is an uncommon complication of IUDs, occurring in 1–1.3/1000.3 Perforation usually occurs immediately after insertion; however, it can occur years later.3–5 Risk factors of uterine perforation include clinician inexperience in IUD placement, an immobile uterus, a retroverted uterus, and the presence of a myometrial defect. Following perforation, IUDs may be anywhere in the pelvis. Most frequently, they are found in adhesions, adherent to the sigmoid colon or omentum, or freely floating in the pouch of Douglas. However, there are several case reports about IUD migration into the bladder, appendix, or bowel and even fistula formation.4 –9 Over 30 years, there are 23 cases reporting colonic penetration by an IUD. The exact mechanism and timing of the sigmoid penetration in our patient’s case is unclear. The patient had excruciating abdominal pain accompanied with vaginal bleeding 3 months after the IUD insertion. This episode could be related to the initial uterine perforation. The patient’s uterus was mildly retroverted, which would be a risk factor for the uterine perforation after IUD insertion. She did not have any other risk factors for perforation, such as previous caesarian sections, or myomectomies. A possible mechanism for the colonic penetration is adherence of the copper IUD to the pericolonic fat, followed by

FIGURE 2. Colonoscopy. Colonoscopy performed the day before the resection reveals one tip of the IUD projecting to the sigmoid colon, located 3 cm from rectosigmoid junction (28 cm from anal verge).

local inflammation and eventual penetration into the sigmoid colon. Another less likely mechanism is uterine enlargement during the patient’s pregnancy, physically displacing the IUD into the sigmoid colon. However, there is no past literature associating pregnancy as a risk factor for extrauterine IUD organ penetration. The symptoms of IUD migration are nonspecific, including abdominal or pelvic pain and abnormal vaginal bleeding. But, as in our patient, it can be asymptomatic. Therefore, clinicians should have a high degree of suspicion to make the diagnosis of IUD migration. As expulsion of IUDs cannot be diagnosed reliably without radiographic evaluation, an abdominal plain radiographs should be obtained to rule out migration. Once IUD migration has been identified, crosssectional imaging such as CT scans or magnetic resonance imaging is recommended to rule out adjacent organ involvement before considering surgical removal. If colonic involvement is suspected, colonoscopy can be useful to confirm the diagnosis before operative removal. Unless surgical risk is excessive, removal of the extrauterine IUD is recommended because of possible adhesion formation that may cause small bowel obstruction, or possible injuries to adjacent organs, to include ovaries, bladder, appendix, or bowel.9 If injuries to adjacent organs are identified, IUD removal is necessary even if the patient is asymptomatic. Retrieval of IUDs can be performed by either laparotomy or laparoscopy.5,7,8 In our case, the densely incorporated IUD in a freely mobile portion of the sigmoid colon was removed via the previous Pfannenstiel incision. In conclusion, when an IUD string is not visible during pelvic examination, appropriate workup, including radiographs, and transvaginal or transabdominal ultrasound should be obtained to confirm the position of the IUD. If IUD migration is suspected, cross-sectional imaging such as CT scans or

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magnetic resonance imaging is recommended to rule out adjacent organ involvement before considering surgical removal. REFERENCES 1. Lessard CR, Hopkins MR: Efficacy, safety and patient acceptability of the EssureTM procedure. Patient Prefer Adherence 2011; 5: 207–12. 2. Mosher WD, Jones J: Use of contraception in the United States: 1982– 2008. Vital Health Stat 23 2010; 29: 1–44. 3. Pirwany IR, Boddy K: Colocolic fistula caused by a previously inserted intrauterine device. Case report. Contraception 1997; 56: 337–9. 4. Verma U, Verma N: Ovarian embedding of a transmigrated intrauterine device: a case report and literature review. Arch Gynecol Obstet 2009; 280(2): 275–8.

5. Mederos R, Humaran L, Minervini D: Surgical removal of an intrauterine device perforating the sigmoid colon: a case report. Int J Surg 2008; 6(6): e60–2. 6. Ko PC, Lin YH, Lo TS: Intrauterine contraceptive device migration to the lower urinary tract: report of 2 cases. J Minim Invasive Gynecol 2011; 18(5): 668–70. 7. Chi E, Rosenfield D, Sokol TP: Laparoscopic removal of an intrauterine device perforating the sigmoid colon: a case report and review of the literature. Am Surg 2005; 71(12): 1055–7. 8. Taras AR, Kaufman JA: Laparoscopic retrieval of intrauterine device perforating the sigmoid colon. JSLS 2010; 14(3): 453–5. 9. Sentilhes L, Lefebvre-Lacoeuille C, Poilblanc M, Descamps P: Incidental finding of an intrauterine device in the sigmoid colon. Eur J Contracept Reprod Health Care 2008; 13(2): 212–14.

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Sigmoid colon penetration by an intrauterine device: a case report and literature review.

The intrauterine device (IUD) is one of the most effective contraceptive methods available today. However, IUDs can cause some serious complications, ...
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