Missing intrauterine contraceptive device presenting with strings at the anus

Abstract

The rare condition of strings of a missing intrauterine contraceptive device presenting at the anus is described. Partial removal was achieved via the rectum and this was followed by a normal uncomplicated pregnancy and delivery.

PIP: Uterine perforation by an IUD has an incidence of .3-.6/1000 insertions and reported by the International Planned Parenthood Federation in 1991. A 23-year old housewife with parity of 2+0 was referred to the gynecology clinic in Trinidad with a diagnosis of a misplaced IUD that had been inserted 3 years before after the 2nd childbirth. She felt for the strings in the vagina at regular intervals but they were missing at the last check, and she indicated that they were felt at the anus. Vaginal examination showed normal vagina and cervix, a normal size retroverted and mobile uterus without adnexal masses. During rectal examination neither the strings nor the IUD could be palpated. X-ray examination confirmed the presence of a copper-7 device in the pelvis, and ultrasound showed it lying posterior to the uterus. Proctoscopy under general anesthesia identified the strings and the long arm of the Cu-7 IUD at about 6 cm from the anal margin. The transverse arm of the IUD was embedded in the rectovaginal septum. Pulling the strings did not succeed in retrieving the device whose transverse arm remained embedded after breakage following scissor dissection at the rectal mucosa. Dilatation and curettage as well as laparoscopy failed to locate the remnant arm. She was instructed about the low likelihood of any problem resulting from it. Post delivery X-ray examination after an uneventful pregnancy confirmed the presence of the retained fragment in the same position as before without displacement during pregnancy. It is probable that the route of retrograde travel of the IUD was via the cervix uteri caused by repetitive uterine contractions which pushed it though the cervix and rectovaginal septum into the rectum.