LAUSR

A 36-year-old lady was referred to the surgical team with a 1-week history of intermittent suprapubic and right lower quadrant abdominal pain with associated nausea, vomiting and low-grade fever. She denied any gynaecological, bowel or urinary symptoms. There were no abnormalities in routine bloods tests but due to significant pain, she underwent computed tomography (CT) of the abdomen and pelvis that demonstrated a foreign body posterior to the uterus in the pouch of Douglas (Fig. 1) with no other abdominal or pelvic pathology. On further questioning, the patient had a significant obstetric past history with gravidity of 9 and parity of 7. She reported an intrauterine contraceptive device (IUCD) insertion in Egypt in 2014, however, had two subsequent pregnancies since. The first pregnancy resulted in a miscarriage requiring dilatation and curettage. Intraoperatively, the IUCD strings were seen through the cervical os and presumed to be correctly positioned and therefore was left in situ. The second pregnancy was delivered via lower segment caesarean section. There was no comment of the IUCD by the patient or involved obstetric team. Two months later, the patient presented to the emergency department with right lower quadrant pain. A CT identified free fluid in the pelvis and an extrauterine IUCD possibly perforating the rectum. She underwent a laparoscopic exploration which identified pus in the pelvis, but no identifiable foreign body was retrieved. Decision was made to not pursue removal of device due to the potential risk of bowel perforation. A follow-up outpatient colonoscopy was performed 5 months later but no intraluminal foreign body was identified. Referral to the gynaecology team for hysteroscopy was therefore recommended; however, the patient was lost to follow-up. Under conservative management consisting of analgesia and intravenous antibiotics, her symptoms improved. The patient was discharged home with the intention to proceed with a repeat colonoscopy. This time, we were able to identify the wired end of the IUCD, situated 20 cm from the anal verge (Fig. 2). A SingleUse Radial Jaw 4 (Boston Scientific, Marlborough, MA USA) Biopsy Forceps was used to grasp the wired end, and with little resistance we were able to pull and retrieve the entire device. The site of puncture on the bowel wall was inspected and no significant bleeding was noted. The patient remained hospitalized for broadspectrum intravenous antibiotics cover and analgesia for 3 days and discharged with oral antibiotics. She was well and symptom free at 2 weeks follow-up. Perforated ICUDs are a rare yet serious complication, with reported incidence at 1.1–1.4 per 1000 insertions. The prevalence of IUCD use in Australia is rising as more primary care physicians are being trained in insertion. Therefore, the number of complications including perforation can be expected to increase too. There are relatively few documented cases worldwide describing surgical removal of perforated IUCDs through the bowel. Our case demonstrates that colonoscopy is a reliable minimally invasive method of removal, with brief hospital stay and negligible morbidity. Our limited experience from this case and review of the literature offers some understanding into the diagnosis and management of malpositioned, perforated or expulsed IUCDs. It is important to first recognize the symptoms, which may include abdominal or pelvic pain, bleeding or unexpected pregnancy. Ultrasound and CT are the recommended modalities of initial radiographical investigation. Valuable information is obtained via imaging at first demonstrating the exact site of migrated device and its anatomical relationship to important intra-abdominal structures. In this case, the migrated IUCD device was extrauterine and ‘sandwiched’ between the uterus and bowel wall. While laparotomy and laparoscopy have been described as effective methods of extrauterine IUCD removal,