Intrauterine contraceptive device is one of the most popular forms of reversible contraception. Though considered as a safe method, uterine
perforation and migration of IUCD into the peritoneal cavity or invasion into one of the adjacent viscera has been reported in English literature.
We are presenting the case of an elderly lady presenting with persistent vaginal discharge which on investigations was found to be due to
enterouterine fistula. As the lady had forgotten about the IUCD placed more than 20 year back, diagnosis could only be established only on
examination of the resected specimen of entero uterine fistula. This case stresses the importance of creating awareness among the users of
IUCD regarding the need for periodic examination to confirm the normal position of IUCD as well as its timely removal once family is complete.
Forgotten intrauterine contraceptive device, Migrated intrauterine contraceptive device, IUCD, Enterouterine fistula, Utero
Intra uterine contraceptive device (IUCD) is one of the most
commonly usedbirth control methods with over one million individuals
adopting this method of contraception worldwide . The popularity of
the device is not only because of its effectiveness but also because of lower
cost, reversibility, one time applicability and excellent safety profile .
However, rarely an IUCD can migrate beyond the uterus into adjacent
organs of the pelvis or the peritoneal cavity. We are presenting a case of
forgotten IUCD which had migrated into ileum resulting in anentero
A 59 yr old post menopausal lady presented with persistent vaginal
discharge and vague lower abdominal pain of 2 years duration. There was
no history of fever or bowel or bladder disturbances. She had received
antibiotic therapy in the past on several occasions though without much
relief. Per vaginal examination revealed tenderness over the uterus,
otherwise no pathology responsible for the white discharge. She was
mother of 5 children and her last delivery was 25 year back. As Ultrasound
examination of the pelvis was inconclusive, contrast enhanced computed
tomography (CECT) of the pelvis was performed. It revealed a loop of
small intestine adherent to the fundus of the uterus with leakage of oral
contrast into the uterus suggestive of enterouterine fistula (Figure 1a).
On exploratory laparotomy, a loop of ileum was densely adherent to the
uterine fundus. Hysterectomy with resection of the involved loop of small
bowel followed by end to end hand sewn anastomosis of the bowel was
performed. Examination of the resected specimen revealed IUCD as the
cause of the fistula (Figure 1b). Post operative course was uneventful and
patient remembered retrospectively that IUCD was placed after her last
delivery and was never taken out.
Figure 1a: CECT pelvis showing a loop of intestine adherent to the
fundus of uterus (Black arrow) and extravasation of contrast material into
the uterine cavity (Red arrow) suggestive of entero uterine fistula.
Figure 1b: Resected specimen showing IUCD (White arrow) and
fistulous communication between fundus of the uterus (Black arrow) and
loop of small bowel (Blue arrow).
Worldwide IUCD is one of the most popular forms of reversible
contraception. It acts by inhibiting the fertilized ovum to get implanted in
the endometrial cavity. Though considered as safe, possible complications
associated with its use include painful abdominal cramps, menstrual
abnormalities, spontaneous expulsion, higher incidence of ectopic
pregnancy, uterine perforation and pelvic inflammatory disease .
Uterine perforation is a rare but potentially serious complication of
IUCD use with reported incidence of 0.12 to 0.68 per 1000 insertions .
Uterine perforation secondary to IUCD placement may be early that is
during or immediately after the placement or delayed that is after several
years of placement. Perforation occurs most commonly through the
posterior wall of the uterus. Perforations may be partial, with some portion
of the device remaining within the endometrial cavity, or complete, with
the device remaining extra uterine . In upto 15% cases, migrated
IUD may invade adjacent visceral organs, with the intestine most often
affected . The migrated IUD can cause perforation or obstruction of
the intestine, mesenteric penetration, rectal strictures, and utero vesical
Enterouterine fistula (EUF), an abnormal fistulous communication
between uterus and the bowel is an entity rarely encountered in the
routine surgical practice. Etiological factors implicated are traumatic or
spontaneous rupture of uterus, malignancy arising from uterus or rupture
of pelvis abscess into both uterus as well as small bowel . Unusual
causes such as that resulting from angio embolization of uterine artery has
occasionally been reported . Migrated IUCD causing EUF has rarely
been reported in English literature.
The clinical presentation in cases of migrated IUCD is highly variable.
Although a small number of patients with present with acute symptoms,
most will be relatively asymptomatic. The IUCD strings are used to
monitor and remove the device. The presence of the string in the vagina
usually means that the IUCD is in situ. A missing string is regarded as the
first sign of perforation in approximately 80% of the cases. The present
patient was not aware of the fact that a missing string is abnormal and
hence never reported it. Over a period of time she forgot that an IUCD
was in situ.
Management of migrated IUCD depends on the mode of presentation.
Current consensus is to remove a migrated IUCD even if it is asymptomatic.
In elective cases, laparoscopic retrieval of the migrated IUCD is preferable
with conversion to open surgery required in upto 22% patients . In
cases when the IUCD has invaded into the adjacent organs or in presence
of acute symptoms, laparotomy may be required. In case of the present
patient, enterouterine fistula of unknown etiology was the tentative
diagnosis and hence laparoscopy was not attempted.
Forgotten IUCD should be a differential diagnosis in any patient with
enterouterine fistula. Awareness needs to be created in the users of IUCD
regarding the need for periodic examination to confirm the normal
position of IUCD as well as its timely removal once family is completed.
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Article Type: Case Report
Citation: Desai AY, Dnyaneshwar S, Pai VD (2015)
Forgotten Intrauterine Contraceptive Device - An
Unusual Cause Of Enterouterine Fistula. J Surg Open Access
1(1): doi http://dx.doi.org/10.16966/2470-0991.102
Copyright: © 2015 Desai AY, et al. This is an
open-access article distributed under the terms
of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Received date: 27 Aug 2014
Accepted date: 01
Published date: 06 Sep 2015