|Year : 2019 | Volume
| Issue : 1 | Page : 60-63
Rectal translocation of intrauterine contraceptive device: A rare and infrequent occurrence
Muhammad Baffah Aminu, Abubakar Muhammad Shehu, Chinedu Aniobi
Department of Obstetrics and Gynaecology, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria
|Date of Web Publication||16-May-2019|
Dr. Muhammad Baffah Aminu
Department of Obstetrics and Gynaecology, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi
Source of Support: None, Conflict of Interest: None
Displacement of copper intrauterine devices (IUDs) is not uncommon complication of these methods of contraception; many literatures have reported the translocation of IUDs to the peritoneum, bladder, and myometrium. A less common complication such as perforation of the ovary has equally been reported. Copper IUD penetrating the rectum is also a rare occurrence because of the anatomical relationship of the uterus and the rectum. This series aimed at highlighting a complication of copper IUD translocating through the uterus to the rectum. We present three cases of displaced IUD managed in our facility over a 2-month period. Two of the clients had their device inserted in primary facilities in the state and one in our institution. All the clients had laparotomy in view of their unusual symptoms. It is imperative for all facility providers to evaluate any client presenting with missing string both clinically and radiologically; they should also acquire or retrain on the criteria for correct insertion of Intra Uterine Contraceptive Device.
Keywords: Copper device, rectal, translocation
|How to cite this article:|
Aminu MB, Shehu AM, Aniobi C. Rectal translocation of intrauterine contraceptive device: A rare and infrequent occurrence. Saudi J Health Sci 2019;8:60-3
| Introduction|| |
Copper intrauterine device (IUD) is one of the most common and effective methods of contraception getting increasing acceptance globally., Its safety and acceptability rely on its noninterference with the body system. Unlike the injectable and other hormonal methods, the copper IUD is inert and its effects are mainly on the uterus, serving as a guard to pregnancy. The copper IUDs are in the long-term reversible contraceptives with the Implanon and Jadelle complimenting the group. Over the years, the device when used correctly has been shown to decrease pregnancy rates by <10% when compared to other methods among adolescents. Complications of IUDs are rare and include uterine perforation; migrations and penetration of adjacent organs have all been documented; occasionally, this complication involved vital organs such as bladder, ovaries, and intestine with or without adverse consequences. Close to a quarter of IUDs inserted can get displaced resulting in some untoward effects.
Although a number of authors have reported a displaced IUD to the rectum, this may be largely due to the proximity of the uterus to the rectum, but not a case series has been reported.,,
This case series aimed at alerting the public on the increasing complications of translocated IUDs due to wrong insertion technique and the need for strict adherence to preinsertion criteria, immediate follow-up postinsertion, and training and continuous retraining of all service providers on the correct procedures for insertion and monitoring.
| Case Series|| |
Mrs. SU was a 27-year-old P2 + 0, 2 alive whose last menstrual period was 3 weeks before presentation. She had copper IUD inserted at a primary health care center 4 years before presentation; she had complained of inability to feel the string 1 year after the insertion, for which an attempt was made for retrieval which was unsuccessful; she was then reassured and sent home. She had no history of lower abdominal pain and abdominal swelling and had neither hematochezia nor melena stools; her menstrual cycles had been regular. She had episodes of lower back pain occasionally that were relieved by analgesics.
All systems examined were normal. Pelvic examination showed a closed cervix with no IUD string seen or felt. Other hematological and biochemical parameters were normal. Plain abdominal X-ray using a control revealed the displaced IUD around the pelvic brim on the left [Figure 1]; this was subsequently confirmed using abdominopelvic ultrasound.
|Figure 1: Displaced intrauterine device in the peritoneum closed to the pelvic brim|
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She had laparotomy that showed IUD in the peritoneal cavity with its stem embedded in the rectum, and other organs were all normal [Figure 2]. Retrieval and repair of rectal injury point were done, and she did well postoperatively and was discharged after 4 days.
Mrs. MAM was a 28-year-old P3 + 0, 2 alive lady whose the last menstrual period was 2 weeks before presentation. She had IUD inserted 1 year ago at the family planning unit of the Abubakar Tafawa Balewa University Teaching Hospital. She complained of inability to feel the string of the IUD for 3 months. She had earlier presented to a private facility and was told that the string was felt rectally and an attempt was made to retrieve it but to no avail. There were history of colicky abdominal pain, no history of abdominal swelling, no bleeding per rectum, and no bloody urine. She had previous cesarean section in her second pregnancy and mesh repair for midline paraumbilical hernia in the same facility with no complications. Other systemic reviews were normal.
Essential findings were on the abdomen where there was an inverted T-shaped incision that healed by secondary intention. Pelvic examination revealed normal-sized uterus, closed Cervix with no string seen or felt. There was no significant finding on digital rectal examination. Hematological and biochemical parameters were normal.
Ultrasound scan showed an anteverted uterus with a linear echogenic focus on the lower uterine segment; the right adnexa showed a normal ovary and a tiny echogenic ring casting shadow posteriorly toward the distal end of the Fallopian tube More Details in keeping with fragment of the IUD. Barium enema also confirmed the IUD within the peritoneal cavity and more to the right, high up to the rectosigmoid junction [Figure 3].
|Figure 3: Displaced intrauterine device seen at the rectosigmoid junction on barium enema|
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She had laparotomy with the findings of filmy adhesions on the anterior abdominal wall. The uterus was levo-rotated with an inflamed right fallopian tube. The T arm of the IUD was embedded in the fimbrial end of the right tube while its stem pierced the rectal peritoneum; both ovaries and the left tube were normal [Figure 4] and [Figure 5]. She had right partial salpingectomy and repair of the rectal injury. She did well and was discharged after 3 days.
|Figure 4: The copper intrauterine device with the stem on the rectosigmoid colon and part of the T buried on the right fallopian tube|
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|Figure 5: The copper intrauterine device after carefully teased out from the rectum and right fallopian tube|
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Mrs. DUH was a 32-year-old civil servant; she was P3 + 0, 3 alive and her last child birth was 3 months before presentation. Her complaints were those of lower abdominal pain and inability to feel the string of the IUD that was inserted 4 weeks before presentation. There was no history of vaginal bleeding as menses had not resumed since her last child birth. There were no other symptoms. She had been told to have uterine myoma during her last antenatal care.
Essential findings were on the pelvic examinations which showed a bulky uterus with absent IUD string. Ultrasound scan done revealed a slightly bulky uterus with intact endometrial cavity; there was an intrauterine device partly on the uterine fundus and peritoneal cavity. There was an anterior myoma of 6 cm × 8 cm in size.
Her packed cell volume was 34% and electrolytes and urea were normal. She had laparotomy, myomectomy, and retrieval of IUDs. Findings were those of anterior myoma of about 5 cm × 7 cm, puncture site on the uterine fundus, IUD string seen at the mid-pelvis with filmy adhesions at the rectosigmoid colon. She did well postoperatively and was discharged after 4 days.
| Discussion|| |
Although all contraceptives have one side effect or the other, some of the methods have fewer untoward effects than the others. Among the rare complications of copper IUD is the risk of perforation which could occur during and or few weeks postinsertion either due to anatomical or technical reasons. Identified reasons would include insertion in the postpartum period, uterine position at the time of insertion, insertion at the time of breastfeeding, as well as the insertion techniques itself; few of these factors were identified in our Cases 2 and 3. In addition, the presence of uterine fibroids at insertion or postinsertion can lead to a distorted endometrial cavity and thus another reason for missing string or a translocated device., Similarly, a retroverted uterus has been shown to be a risk factor for displaced IUD accounting for about 10% of all occurrences.
As it is common with most cases of translocation, IUDs can be seen during retrieval in the pouch of Douglas in the anteverted uterus and the anterior pouch or vessicouterine pouch for a retroverted uterus, such is not surprising looking at the anatomy of the organs and the instruments used which alone or together with the device can be the reason for the rare but usual complication. The cases reported had device located in the posterior pouch largely because of the anteverted position of the uterus in all cases. Uterine perforation by IUDs has a usual time of occurrence which is usually between 8 weeks and 1 year postinsertion.
Radiological investigations are very vital in the management of patients with translocated IUDs, in our series. Ultrasound and plain X-ray were useful, in developed centers. CT scan is vital for both location and retrieval process since it gives the exact location of the device and whether or not it is embedded in the wall of the affected viscera, but that was not used because of unavailability and cost.
Displaced IUDs into the peritoneal cavity through uterine perforation can be retrieved via laparotomy or laparoscopy., In those still within the uterine cavity, a retrieval hook can be use blindly for retrieval or under vision through hysteroscopy. The blind procedures are associated with all the attendant risks of organ damage including avulsions of vital organs. The choice of laparotomy over laparoscopy in this series was because of the uncertainty in location, adhesions from previous cesarean section and mesh repair, as well as the co-existence of uterine myoma; all of these can make laparoscopic retrieval difficult, especially in the hands of the unskilled. Sigmoidoscopy can also be performed where the IUD or its portion is visualized per rectum and device was removed per rectum without much complication; where this is not possible, a mini-laparotomy or laparoscopy will suffice.
| Conclusion|| |
Uterine perforation and translocation of IUD to the rectum is a rare complication of copper device when wrongly inserted. Facility providers must be aware of the risks associated with perforation and translocation of IUDs before and after insertion. The key to a successful placement is the clinical skills of the provider.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cheung ML, Rezai S, Jackman JM, Patel ND, Bernaba BZ, Hakimian O, et al.
Retained intrauterine device (IUD): Triple case report and review of the literature. Case Rep Obstet Gynecol 2018;2018:9362962.
Gerkowicz SA, Fiorentino DG, Kovacs AP, Arheart KL, Verma U. Uterine structural abnormality and intrauterine device malposition: Analysis of ultrasonographic and demographic variables of 517 patients. Am J Obstet Gynecol 2019;220:183.e1-183.e8.
Lindberg LD, Santelli JS, Desai S. Changing patterns of contraceptive use and the decline in rates of pregnancy and birth among U.S. Adolescents, 2007-2014. J Adolesc Health 2018;63:253-6.
Aktoz F, Gunes AC, Kuru O, Tuncer ZS. Removal of a missing intrauterine device via laparotomy after 28 years of insertion: A case report. Gynecology Obstetrics & Reproductive Medicine 2018;1-3.
Sun X, Xue M, Deng X, Lin Y, Tan Y, Wei X. Clinical characteristic and intraoperative findings of uterine perforation patients in using of intrauterine devices (IUDs). Gynecol Surg 2018;15:3.
Gul K, Gul P, Gul P, Parveen T. Migrated IUCD into the pelvic organs and abdomen: Case series. J Soc Obstet Gynaecol Pak 2018;8:131-4.
Toumi O, Ammar H, Ghdira A, Chhaidar A, Trimech W, Gupta R, et al.
Pelvic abscess complicating sigmoid colon perforation by migrating intrauterine device: A case report and review of the literature. Int J Surg Case Rep 2018;42:60-3.
Lauer JK, King CR. Laparoscopic removal of a perforated IUD in the rectosigmoid colon. J Minim Invasive Gynecol 2018;25:S153-4.
Günakan E, Buluş H, Polat F. Colonic perforation due to the migration of an intrauterine device (IUD): Surgical management for acute abdomen. Ortadogu Med J 2018;10:1-7.
Dzib-Calan EÁ, Morales-Pérez JI, Acuña-Prats R, Leal-Mérida G, Larracilla-Salazar I. Endoscopic management in the migration to rectum of an intrauterine device. Case report. Ginecol Obstet México 2018;86:146-50.
Wildemeersch D, Hasskamp T, Goldstuck N. Intrauterine devices that do not fit well cause side effects, become embedded, or are expelled and can even perforate the uterine wall. J Minim Invasive Gynecol 2015;22:309-10.
Zapata LB, Whiteman MK, Tepper NK, Jamieson DJ, Marchbanks PA, Curtis KM. Intrauterine device use among women with uterine fibroids: A systematic review. Contraception 2010;82:41-55.
Thapa S, Dangal G, Karki A, Pradhan HK, Shrestha R, Bhattachan K, et al.
Missing intrauterine device copper-T: Case series. J Nepal Health Res Counc 2018;16:354-6.
El Saadi A, Mohandes I, Emad M, Abdulbaqi H. The role of CT scan in laparoscopic retrieval of a perforated intrauterine device (IUD). Gynaecol Surg 2004;1:248-50.
Gill RS, Mok D, Hudson M, Shi X, Birch DW, Karmali S. Laparoscopic removal of an intra-abdominal intrauterine device: Case and systematic review. Contraception 2012;85:15-8.
Asto MR, Habana MA. Hysteroscopic-guided removal of retained intrauterine device: Experience at an academic tertiary hospital. Gynecol Minim Invasive Ther 2018;7:56-60.
] [Full text]
Shrimal D, Vasudeva A, Hebbar S, Chawla A. Ureteric avulsion following blind attempts at retrieval of intrauterine contraceptive device: A clinical lesson to primary care givers. J Clin Diagn Res 2018;12.
Sepúlveda WH. Perforation of the rectum by a copper-T intra-uterine contraceptive device; a case report. Eur J Obstet Gynecol Reprod Biol 1990;35:275-8.
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