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BMJ Case Rep. 2010; 2010: bcr0320102836.
Published online 2010 December 6. doi:  10.1136/bcr.03.2010.2836
PMCID: PMC3030138
Learning from errors

Intrauterine contraceptive device with rectal perforation and strings presenting at the anus

Abstract

A 36-year-old grand multiparous midwife presented to the gynaecological unit of the University of Uyo Teaching Hospital with the string of an intrauterine contraceptive device (IUCD) protruding from her anus. She had had a copper IUCD inserted at a health centre 8 years earlier. However, 4 months later she noticed that she no longer felt its strings and had another IUCD inserted in the same facility when the first device was not located. Four months prior to presentation, she presented to a private clinic when she no longer felt the strings of the second IUCD. The device in the uterus was removed in the private clinic and she was referred to the teaching hospital. At the teaching hospital rectal examination and plain x-ray revealed the presence of a device. Under general anaesthesia, the device was successfully removed in theatre through the rectum with no postoperative complications.

Background

Perforation of the rectum with the strings of an IUCD protruding from the anus is very rare and to the knowledge of the authors has not previously been reported in Nigeria.1

In addition, this case highlights certain pitfalls in the management of the patient.

Case presentation

The patient presented with the strings of an IUCD protruding from her anus (figure 1). Her medical history was not significant. She was a divorcee and a midwife who did not smoke or drink alcohol.

Figure 1
The strings of the IUCD protruding from the anus.

Investigations

  • [triangle] Trans-abdominal ultrasound scan showed normal pelvic findings.
  • [triangle] Plain abdominal x-ray (with a sound inserted in the uterine cavity) showed a copper T IUCD lying transversely posterior to the sound outside the uterine cavity, subjacent to the rectum (figure 2).
    Figure 2
    The IUCD lying transversely posterior to the uterine sound, outside the uterine cavity.

Treatment

The IUCD was removed via the rectum (figure 3).

Figure 3
The copper T IUCD being removed from the rectum.

Outcome and follow-up

Good outcome with no complications after removal.

Discussion

Uterine perforation is a minor but serious complication associated with the use of an IUCD.2 In about 80% of perforations, the devices are located freely in the intraperitoneal space.2 3 Rectal perforation with strings protruding from the anus is exceptionally rare with very few cases reported in the literature.

Learning points

  • [triangle] Rectal perforation by an IUCD with strings protruding from the anus several years after its insertion can occur but is very rare.
  • [triangle] Although uterine perforation is rare, missing strings are the first sign in approximately 80% of cases and inability to locate an intrauterine device should be considered a uterine perforation until proven otherwise.
  • [triangle] Family planning providers in peripheral centres should receive proper training and periodic re-training on evaluation methods for examining clients when they present with missing IUCDs.

Footnotes

Competing interests None.

Patient consent Obtained.

References

1. Gupta S, Kirkman R. Intrauterine devices-update on clinical performance. Obstet Gynaecol 2002;4:37–44
2. Population Reports. New Attention to the IUD 2006. Series B, No 7, 2006
3. Abasiattai AM, Bassey EA, Udoma EJ. Profile of intrauterine contraceptive device acceptors at the University of Uyo Teaching Hospital, Uyo, Nigeria. Ann Afr Med 2008;7:1–5 [PubMed]

Articles from BMJ Case Reports are provided here courtesy of BMJ Group