Long-term sequelae of a misplaced intrauterine contraceptive device.

Abstract

Intrauterine devices (IUD) have been widely available worldwide since the invention of thermoplastic IUD by Margulies in the 1960s and are amongst the most effective, long-acting and reversible contraceptives with failure rates of less than 1%.1 Uterine and other organ perforation is a rare, serious complication of IUD use with variable clinical severity ranging from acute surgical emergency to incidental finding. The multinational study EURAS-IUD described a perforation rate of 1.6–2.1 per 1000 insertions within 60 months of insertion.2 Timely removal of displaced IUD by endoscopy or surgery is recommended by WHO.3 We report a case of a perforated sigmoid colon with phlegmon requiring anterior resection, resulting from an IUD insertion approximately 40 years ago. A 62-year-old was referred to a gastroenterologist for investigation of PR bleeding and left iliac fossa pain with constipation. She migrated to Australia more than 20 years ago from the Middle East. Her past medical history included caesarean section, hysterectomy, thyroidectomy and type II DM. Initial colonoscopy showed an angulated stricture in the sigmoid colon associated with a non-circumferential lesion, which demonstrated granuloma when biopsied (Fig. 1). Suspecting malignancy computerized tomography (CT) of chest, abdomen and pelvis was organized which revealed a T-shaped linear dense foreign object perforating through colonic wall with some surrounding stranding (Fig. 2). The patient reported that she had an IUD inserted more than 40 years ago for contraception and remembered being told that it must have fallen out, as her doctor was unable to find it on attempted removal. Subsequently she fell pregnant, underwent caesarean section and then had a hystectomy around the time of her menopause. The patient underwent laparoscopic high anterior resection for phlegmonous mass of rectosigmoid colon. Extensive adhesiolysis was required to mobilize the sigmoid colon out of the pelvis, which revealed the IUD tip protruding out of the bowel wall. Her upper rectum and descending colon appeared healthy and an end-to-end colorectal anastomosis was created with a circular stapler. The patient did not require a defunctioning stoma, made an uneventful recovery and was discharged on post-operative day 6. On histological examination, the resected rectosigmoid colon measured 10.8 cm by 4.5 cm with a 7 cm granulomatous fistula tract formed by the IUD perforating into the bowel (Fig. 3). PubMed literature search of peer-reviewed articles in English was conducted on October 27th 2021 with search terms ‘intrauterine device’, ‘colon’ and ‘perforation’ yielding 49 results of which 45 were appropriate for our review. There are two hypothesised mechanisms for IUD perforation resulting in complications: immediate traumatic perforation at the time of insertion or gradual perforation due to uterine contraction. Recognized risk factors for IUD perforation include being immediately post-partum and subsequent pregnancy.4 The EURAS-IUD study suggested that the majority of early perforations present with pain or bleeding; however 58–75% of patients with uterine perforation diagnosed more than a year after insertion were asymptomatic.2 Of the 39 009 women included in prolonged follow-up cohort up to 60 months after IUD insertion, 75 patients had perforations but none suffered injury to adjacent organ.2 About 59–66% of perforated IUDs were removed laparoscopically when intraperitoneal.2 Other authors have reported successful colonoscopic removal of migrated intraluminal IUDs.5 Intestinal perforations are exceedingly rare and the most common sites are reported as sigmoid colon, small intestine and rectum. Systematic review by Gill et al. showed laparotomy conversion rate of 34.6–68% in patients undergoing laparoscopic surgery for IUD associated complications, often due to adhesions and associated bowel perforation.5 To our knowledge, this is the first case where an IUD caused an inflammatory colonic stricture by migrating through the uterus into the sigmoid colon wall decades after insertion. Mass and foreign body reaction surrounding migrated IUDs have been reported in the inguinal canal and the abdominal wall.6 This case emphasizes the need for diligent follow-up of patients with IUDs and prompt investigation if attempt to remove is unsuccessful. Open access publishing facilitated by University of New South Wales, as part of the Wiley - University of New South Wales agreement via the Council of Australian University Librarians.