An Unusual Case of a Forgotten Intrauterine Contraceptive Device Which was Found Embedded in the Rectosigmoid ColonCorrespondence Address :
Mahesha Navada H
Assistant Professor, Department of Obstetrics and Gynaecology,
Father Muller Medical College, Mangalore â€“ 565 002
Mobile No: 9448545301
An intrauterine contraceptive device (IUD) is an effective, safe and convenient contraceptive method. It can cause serious complications like uterine perforation during the insertion process. The perforation of the bowel by the IUD is usually symptomatic, but asymptomatic colon perforation has rarely been reported. We are reporting one such case of a forgotten IUD, which perforated through the uterine wall into the rectosigmoid colon and was found incidentally during hysterectomy.
Intrauterine contraceptive device, uterine perforation, rectosigmoid colon
A 45 year old para two woman was admitted with abnormal uterine bleeding, following one year of cessation of menstruation. She had previous vaginal deliveries and her last childbirth was 16 years back. She was a widow for the past six years. The intrauterine contraceptive device (IUD) was inserted 16 years back. There was no history of complications after the insertion. The patient had forgotten about the IUD. Her genital examination revealed bleeding through the os, with no thread seen or palpation. Her pelvic ultrasound revealed a bulky uterus with a thickened endometrium. The IUD was not visualized.
A diagnostic fractional curettage was done and histopathology revealed simple endometrial hyperplasia. She opted for totalabdominal hysterectomy with bilateral salphingo oophorectomy [TAH with BSO] after counselling. Intra operatively, adhesions were found between the posterior wall of the uterus and the sigmoid colon. The serosal layer of the sigmoid colon at the recto sigmoid junction appeared as if it had moved into the posterior wall of the uterus (Table/Fig 1) after dissection. On gentle dissection and traction, the bowel wall was found to be separated from the uterus. The vertical arm of the IUD, devoid of the copper wire, was found to be coming out through the perforation in the posterior wall of the uterus (Table/Fig 2). The IUD was found with the horizontal arm still embedded in the wall of the colon (Table/Fig 3) . TAH with BSO was completed. The horizontal arm was exposed in the bowel wall after the incision of the bowel surface at the embedded site. Apparently, the lumen was not perforated. Thelumen opened about two centimetres, on separating the IUD from the fibrosed attachment. Later, the bowel wall was closed in layers after removing the IUD. Her postoperative recovery was good and uneventful. She was discharged on the seventh day.
The IUD is a commonly used and effective reversible method of contraception. Uterine perforation is one of the serious complications which are observed during the IUD insertion. Its estimated incidence is less than one per 3000 insertions (1). The IUD may perforate through the uterine wall into the pelvic or the abdominal cavity or into the adjacent organs. The patient may present with symptomslike abdominal pain and excessive bleeding. Abdominal pain, fever and diarrhoea may be the symptoms which may be associated with bowel perforation (2). Asymptomatic patients with silent perforation also have been reported (3). Finding an asymptomatic bowel perforation by the IUD at laparotomy during hysterectomy is rare, but such a case was reported (4). Our case also had adhesion around the site of perforation, which was similar to the reported case (5). Markovitch O et al speculated that adhesions are an early process at the time of the perforation and that once they are formed there is no additional adhesion formation around them as time progresses (6). So, they prevent the further displacement of the IUD. Hence, in our case, the bowel wall was found to be attached inside the uterine perforation which covered the limbs of the IUD and so, it remained asymptomatic.
It is also possible that the initial uterine symptoms may have been relieved by symptomatic treatment. As the perforation did not involve the lumen, she remained asymptomatic in the later years.
In conclusion, asymptomatic perforation of the rectosigmoid colon which is caused by an IUD can occur. Skilful insertion is important to avoid complications. The need of a proper follow up examination after the insertion of an IUD should be highlighted.
Skilful insertion is important to avoid complications. The need to conduct a proper follow up examination after the insertion of an IUD is highlighted
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