Journal of Surgical Case Reports, 2016;2 , 1–2

doi: 10.1093/jscr/rjw004
Case Report

CASE REPORT

An unconventional therapeutic approach to a migratory

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IUD causing perforation of the rectum
Grace W. Ma1,2,*, Andrew Yuen1, Paraskevi A. Vlachou3,4, and
Sandra de Montbrun1,3
1
Department of General Surgery, University of Toronto, Canada, 2Mount Sinai Hospital, Toronto, Canada,
3
St Michael’s Hospital, Toronto, Canada, and 4Department of Medical Imaging, University of Toronto, Canada
*Correspondence address. Tel: +1-647-822-8192; Fax: +1-461-864-5565; E-mail: gw.ma@mail.utoronto.ca

Abstract
Intrauterine devices (IUDs) are a commonly used form of contraception. The risk of perforation and migration of these devices
have been reported to be 1 in 1000. Migration into the rectum is even more uncommon. The following case illustrates a
previously healthy 37-year-old woman who experienced a perforation and migration of an IUD into the rectum necessitating
endoscopic removal. To our knowledge, this complication of IUD and subsequent endoscopic removal has not been previously
described and presents a viable first-line therapeutic option in a stable patient.

INTRODUCTION which demonstrated protrusion of the IUD into the rectal lumen.
The patient was then referred to a colorectal specialist.
The intrauterine device (IUD) is a popular method of contraception
An magnetic resonance imaging (MRI) performed 1 month
with worldwide use approaching 15% [1]. It is, however, associated
following the original CT demonstrated the T-arms of the IUD
with an estimated uterine perforation rate of 1 per 1000 insertions
to have migrated within the rectum ∼10–12 cm above the anorec-
[1, 2]. Various retrieval methods of migrated extra-uterine IUDs
tal junction at or just above the peritoneal reflection.
have been described in the literature including endoscopy, laparos-
At this point, the patient was relatively asymptomatic except
copy or laparotomy. The following case report outlines the endo-
for non-cyclical painless bleeding. She was consented for transa-
scopic retrieval of a migrated IUD into the rectal lumen.
nal IUD extraction with the possibility of a laparoscopic extrac-
tion and repair. The patient was brought to the operating room,
CASE REPORT given sedation and positioned in left lateral decubitus for endo-
A 37-year-old woman had an IUD inserted 1 year after her only scopic extraction. A flexible gastroscope was advanced to the
pregnancy. The patient experienced post-procedural bleeding. level of the T-arms which were caught proximal to a rectal fold.
At her follow-up, the strings of the IUD were not visualized, The arms were grasped with alligator forceps and manipulated
which was suspicious for IUD migration. An attempt at laparo- in a proximal direction to dislodge the device. Once the entire
scopic retrieval was unsuccessful. A computed tomography (CT) IUD was free, the stem was pulled distally and removed transan-
scan showed migration of the IUD with the T-arms of the device ally. The scope was then reinserted, and the rectal wall appeared
seen posterior to the left vaginal fornix with the shaft within the healthy with no evidence of intraabdominal perforation. The pa-
lower rectum (Fig. 1). A general surgeon was subsequently con- tient tolerated the procedure well and was discharged home after
sulted, and a diagnostic flexible sigmoidoscopy was performed, an overnight observation period.

Received: November 8, 2015. Accepted: January 4, 2016

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1
 2 | G.W. Ma et al.

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Figure 1 (a) Sagittal CT Scout view shows IUD (arrow) in very posterior location, probably within the rectum. (b) Sagittal contrast-enhanced CT of the pelvis showing
the extra-uterine position of the contraceptive device (arrow) posterior to the uterus. (c) Axial contrast-enhanced CT of the pelvis reveals extra-uterine position of the
contraceptive device arms (arrow) posterior to the cervix (*). (d) Axial contrast-enhanced CT of the pelvis showing the extra-uterine position of the stem of the
contraceptive device within the rectal lumen (arrow) after perforating the uterus (*).

A follow-up CT was performed on Postoperative Day 2 with with proper technique and preoperative planning. This case de-
rectal contrast showing no extravasation of contrast to suggest scribes the successful retrieval of an intraluminal IUD using care-
a leak. The patient was subsequently discharged from hospital ful endoscopic manipulation to extract the device without
without complication. further injury to the rectal wall.

DISCUSSION
CONFLICT OF INTEREST STATEMENT
Many IUD-associated uterine perforations are asymptomatic,
None declared.
and the actual incidence may be higher than reported [3].
Although uterine perforation may be painless, migration into
the gastrointestinal tract may present as chronic lower abdomin-
al pain, fever or diarrhea [3].
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