REV ARGENT COLOPROCT | 2024 | VOL. 35, N
o
2 CASE REPORT
MIGRATION OF IUD TO THE RECTUM: ENDOSCOPIC REMOVAL Getar S., et al.
Migration of intrauterine device to the rectum: endoscopic removal
Sofía Getar
1
, Julieta Y. Espino
1
, Mauro Trama
1
, Fabio Leiro
1
, Stephanus Daniela
2
División de Cirugía General
1
y División de Tocoginecología
2
, Hospital José María Penna, Ciudad de Buenos Aires, Argentina
ABSTRACT
The intrauterine device (IUD) is one of the most used contraceptive
methods due to its safety and effectiveness. It is generally well
tolerated, however, there are complications such as expulsion,
uterine perforation and migration. Rectal migration of the device is a
rare complication, with few cases described in the literature. We
present a 21-year-old female patient with rectal migration of the IUD
and its removal by endoscopy.
Keywords: intrauterine device, rectal migration, endoscopy
INTRODUCTION
Intrauterine devices constitute 23% of reversible contracep-
tive measures worldwide. Although it is considered an effec-
tive and safe method, its use can present complications, of
which the most serious are uterine perforation and device
migration. Rectal migration is a rare complication; according
to our bibliographic search, there are 22 cases published in
the world. We consider that the decision on how to remove
the device should be case-specific, according to its exact
location and the size of the fistulous orifice, if found. For
this, imaging methods are important, as well as endoscopy,
which can also be useful for therapeutic purposes, as we will
demonstrate in this case.
CASE
A 21-year-old female patient with a history of intrauterine
device (IUD) placement in October 2021 attends the clinic
due to a foreign body sensation and threads coming out of the
anal canal. During the proctological examination, the threads
of the device are evident (Fig. 1). During the digital rectal
examination, a tonic sphincter and smooth rectal mucosa are
observed, and approximately 8 cm from the anal verge a
foreign body is palpated on the anterior wall. A transvaginal
ultrasound reports the presence of the IUD outside the uterine
cavity. A pelvic X-ray shows the IUD in the presacral re-
gion, in rectal topography (Fig. 2). Hysteroscopy and colon-
oscopy are scheduled under sedation. In the hysteroscopy,
performed first by the Gynecology Service, the IUD is not
found in the uterine cavity. The mucosa is intact and there is
no evidence of communication with the rectum.
Next, during colonoscopy, the IUD is identified 10 cm from
the anal verge, on the anterior wall of the rectum. Its extrac-
tion is achieved with an endoscopic foreign body forceps
(Fig. 3). The defect through which the device had protruded
is less than 5 mm, with no evidence of bleeding. The pres-
ence of a rectouterine fistula was ruled out, inferring that the
device compromised only the wall of the rectum. The patient
is discharged after 6 hours. She is scheduled for subsequent
outpatient checkups.
Figure 1. Proctological examination. IUD thread can be seen
coming out through the anus.
Figure 2. Pelvic X-ray. A. Anteroposterior view. IUD migration. B. Lateral view. The IUD is seen in the presacral area.
The authors declare no conflict of interest. Julieta Yanet Espino: juliiyanet@gmail.com
Received: October 2, 2023. Accepted: January 30, 2024
Sofía Getar: https://orcid.org/0009-0003-0041-9098, Julieta Espino: https://orcid.org/0000-0002-5929-0773, Mauro Trama: https://orcid.org/0000-0001-5197-3185,
Fabio Leiro: https://orcid.org/0000-0002-9477-2997, Stephanus Daniela: https://orcid.org/0009-0000-7378-5337
REV ARGENT COLOPROCT | 2024 | VOL. 35, N
o
2 CASE REPORT
MIGRATION OF IUD TO THE RECTUM: ENDOSCOPIC REMOVAL Getar S., et al.
Figure 3. Colonoscopy. A and B. Endoscopic removal of IUD located in the rectum. C. IUD outside the rectal cavity. D. Endoscopic control after
removing the IUD.
DISCUSSION
The IUD is a safe and effective contraceptive method, with
the “T” type with copper being the most used worldwide.
1
Its
possible complications include bleeding, ectopic pregnancy,
uterine perforation, infection and, less frequently, migration
or fistula formation into the digestive system. The incidence
of migration varies between 0.2 and 0.87 per 1,000 inser-
tions, although significant under-registration is recognized.
Risk factors that predispose to this complication include the
use of copper IUD, placement during lactation or less than 6
months after delivery, postpartum amenorrhea, retroverted
uterus, nulliparity, history of abortion, and limited staff
experience of the health personnel, among others.
2
Uterine perforation with migration is considered primary or
immediate if it occurs during IUD insertion due to penetrat-
ing injury to the myometrial tissue. However, it can also
occur secondarily or late due to gradual erosion through the
myometrium. The clinical presentation of early migration
usually manifests with sudden and intense pain and/or genital
bleeding. On the other hand, in late perforation the interval
between insertion and diagnosis can vary from days to sever-
al years, although it usually occurs during the first months
and up to a year after insertion.
3-4
Migration due to uterine perforation should be considered in
case of non-visualization of the device or its visualization
outside its normal location within the uterus, using transvagi-
nal and/or transabdominal ultrasound, as well as simple
abdominal x-ray, abdominopelvic computed tomography
with contrast or magnetic resonance imaging.
5
When a perforation is identified, it is recommended to re-
move it as soon as possible, regardless of the type of device
and its location. Endoscopic techniques can be used, either
colonoscopy, hysteroscopy or cystoscopy depending on the
location.
6
Rectal perforation due to IUD, generally oligosymptomatic,
is rare, with few cases described in the literature. Although
rectal migration involves communication with the genital
tract, the question is whether it will lead to a fistula or not. In
the literature analyzed, no rectovaginal or rectouterine fistu-
las due to migration of the IUD have been described, alt-
hough cases of fistulas to the small intestine and colon have
been reported.
After identifying the device in the rectum, a complete endo-
scopic removal may be feasible. The type of material favors a
low reaction to foreign bodies. This condition, added to the
mostly extraperitoneal rectal anatomy, determines a usually
safe endoscopic removal, without significant injury to the
surrounding tissues and with a minimal residual fistulous
tract that is repaired spontaneously. A hole smaller than 0.5
cm can close spontaneously in these cases, however, for
larger defects the use of endoclips or plasties is described.
7
CONCLUSION
Perforation and rectal migration of the IUD, generally oligo-
symptomatic, is rare. It should be suspected when the device
was not removed and its uterine location is not identified.
The diagnosis is usually made by a simple X-ray or transvag-
inal ultrasound. It should be removed as soon as possible
after diagnosis, even in asymptomatic cases. Complete
endoscopic removal may be feasible and safe, and no cases
of rectal fistulas after device migration and removal have
been described in the literature.
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