Introduction

Intra uterine contraceptive device (IUCD) insertion as a contraceptive method is an important part of family planning programme in India. Few complications such as infection, expulsion and perforation can occur following insertion of IUCD. Perforation caused by an IUD is an uncommon but serious complication with a incidence of 1/1,000 insertions [1] and it is rare with postpartum IUCD insertion. It is most commonly seen through the posterior wall of the uterus[2]. Uterine perforation eventually cause contraception failure and can even lead to major surgical intervention which is demoralising for the patient and doctors.

Case Report

A 35 year old woman para 2(both vaginal delivery) visited gynae outpatient department of Midnapore Medical College and Hospital with complain of spontaneous expulsion of Cu IUCD 375 (Fig:1) from anus during defecation. She was also having sharp pain around anus during defecation for past one week. She didn’t have complain of bleeding per rectum or constipation. There was no history of chronic pelvic pain. Post-partum Cu IUCD 375 was inserted following vaginal delivery five years back. She didn’t have any complains after that. Then after 6 months of insertion she didn’t find the IUCD thread in her vagina. She went for consultation from a private doctor and was advised ultrasonography of lower abdomen and pelvis. In ultrasonography no IUCD was found in the uterus. Then she thought that IUCD has been spontaneously expelled and didn’t go for any follow up visit. No straight X-ray abdomen was done at that time. She also started to take oral contraceptive pills on her own.

Fig. 1: Cu IUCD hanging through anus

On general examination her vitals were stable. On per-abdominal examination: abdomen was soft, no tenderness noted. On gynaecological examination, the perineum, vulva and vagina were normal, the uterus was anteverted and of normal size, and bilateral fornices were normal. On speculum examination, the cervix was healthy. The Cu IUCD 375 was hanging down from anus with both the strings attached inside. Per rectal examination was done. Both the ends of the threads of Cu IUCD was adhered to the rectal mucosa approximately 6 cm above the anal verge. Urine pregnancy test was negative. Ultrasonography of lower abdomen and pelvis, Straight Xray of abdomen and pelvis and proctoscopy was done to locate the ends of the string of Cu IUCD.

In proctoscopy ends of the Cu IUCD thread were attached to rectal mucosa 5 cm above the anal verge (Fig 2).

Fig. 2: Proctoscopic image showing Cu IUCD thread attached to rectal mucosa

The ends of the threads held with the help of artery forceps then rotated and pulled outside with gentle traction. Finally, the Cu IUCD came out with both the threads intact. After the procedure no rectal bleeding, major injury except for a very small mucosal defect. No post procedure complication noted. The patient was followed up for one month and no complication was noted.

Discussion

There are many studies which have reported intestinal perforation of IUCD requiring laparotomy or rectal route of removal. In a review of 356 cases of perforated IUCD’s, 20 cases of intestinal perforation were reported, of which nine involved the rectosigmoid. All required laparotomy for their removal[3]. In a case report there were 8 cases of IUCD perforation through rectosigmoid junction which were removed by rectal route [4]. However perforation of IUCD following post placental insertion is rare[5] and to the best of our knowledge only one case has been reported of uterine perforation after post placental IUCD insertion following vaginal delivery[6].

Once completely perforated Cu IUCD can occupy any part of the peritoneal cavity. Trans-located Cu IUCD has been found in different parts like pouch of Douglas, adherent to adnexa, broad ligament, buried into omentum[3]. More serious complication occurs when translocated Cu IUCD perforates through adjacent organs like bladder, intestine, sigmoid colon, rectum[7]. The symptoms of an IUD perforation are diverse varying from a subsequent unwanted pregnancy to irritant lower urinary tract symptoms, chronic pelvic pain, peritonitis and fistulae or abscess formation depending on the organ of penetration and the interval since penetration and the patient’s response [8]. However in our case patient didn’t have any symptoms other than sharp pain at anus for one week just before expulsion of IUCD.

Ultrasonography and X-ray are helpful in diagnosis. The computed tomography scan is also a helpful imaging technique. In our case ultrasonography was done where no IUCD found in utero but no X ray was done. An X ray of lower abdomen could identify an IUCD much earlier if it was done in time.

Most cases of Cu IUCD perforation into intestine requires surgical intervention like laparoscopy, laparotomy, colonoscopy, sigmoidoscopy, etc. But our case is unique in it’s presentation as the patient had a spontaneous expulsion of Cu IUCD and minimal surgical intervention was required.

From our case it is noted that whenever there is missing thread during examination it should be taken seriously. Only Ultrasonography is not enough for diagnosis of missing IUCD. X Ray can be added to find out IUCD as it is radio opaque.

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