IUCD-related uterine perforation

Changed by Joshua Yap, 27 Feb 2023

Disclosures - updated 15 Jul 2022: Nothing to disclose

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IUCD-related uterine perforations are one of the causes of uterine perforation. It is a rare, but serious complication of an intrauterine contraceptive device (IUCD), and is often clinically silent.

Epidemiology

The incidence rate is reported at ~2 in 1000 ².

Aetiology

~~Uterine perforation is thought to be related to low oestrogen levels leading to uterine shrinkage.~~

Risk factors

postpartum period <6 months
lactation
amenorrhoea may increase the risk of perforation

Associations

atrophic/postpartum uterus
uterine structural abnormalities ⁵
large fibroids ⁵

Clinical presentation

Perforation of the uterus at the time of insertion may be clinically silent or cause significant pelvic pain. A late perforation may be asymptomatic, or present with non-specific lower abdominal pain. In all cases, the visible ~~'strings'~~"strings" will be missing at direct inspection. Peritoneal sepsis is a rare presentation.

Pathology

IUCD-related uterine perforation ranges from embedment in the myometrium to complete transuterine perforation with a migration of the intrauterine contraceptive device into the peritoneal cavity ⁶.

Embedment refers to the penetration of an intrauterine contraceptive device into the endometrium or myometrium without extending through the serosa.

Intra-abdominal migration occurs when the intrauterine contraceptive device is freely floating in the abdomen or pelvis encased in adhesions or adherent to bowel or the omentum. Adhesions can lead to infertility, chronic pain, and intestinal obstruction ⁶.

Aetiology

Uterine perforation is thought to be related to low oestrogen levels leading to uterine shrinkage.

Radiographic features

Ultrasound is the recommended first-line investigation ³ in all women in whom the ~~‘strings’~~"strings" cannot be visualised. Orthogonal radiographs are often the second line. CT can be used in complex cases where visceral involvement or surgical difficulty is suspected.

Plain radiograph

an intrauterine contraceptive device lying lateral to midline may suggest the diagnosis

Ultrasound

may have a normal endometrial cavity on ultrasound
hyperechoic linear structure lying outside the uterus

Treatment and prognosis

Treatment depends on the degree of perforation and whether there are any complications (such as peritoneal sepsis or intestinal obstruction).

-<p><strong>IUCD-related uterine perforations</strong> are one of the causes of <a href="/articles/uterine-perforation">uterine perforation</a>. It is a rare, but serious complication of an <a href="/articles/intrauterine-contraceptive-device-1">intrauterine contraceptive device (IUCD)</a>, and is often clinically silent. </p><h4>Epidemiology</h4><p>The incidence rate is reported at ~2 in 1000 <sup>2</sup>.</p><h5>Aetiology</h5><p>Uterine perforation is thought to be related to low oestrogen levels leading to uterine shrinkage.</p><h5>Risk factors</h5><ul>
~~-<li>postpartum period <6 months</li>~~
~~-<li>lactation</li>~~
~~-<li>amenorrhoea may increase the risk of perforation</li>~~
+<p><strong>IUCD-related uterine perforations</strong> are one of the causes of <a href="/articles/uterine-perforation">uterine perforation</a>. It is a rare, but serious complication of an <a href="/articles/intrauterine-contraceptive-device-1">intrauterine contraceptive device (IUCD)</a>, and is often clinically silent. </p><h4>Epidemiology</h4><p>The incidence rate is reported at ~2 in 1000 <sup>2</sup>.</p><h5>Risk factors</h5><ul>
+<li><p>postpartum period <6 months</p></li>
+<li><p>lactation</p></li>
+<li><p>amenorrhoea may increase the risk of perforation</p></li>
~~-<li>atrophic/postpartum uterus</li>~~
~~-<li>uterine structural abnormalities <sup>5</sup>~~
~~-</li>~~
~~-<li>large <a href="/articles/uterine-leiomyoma">fibroids</a> <sup>5</sup>~~
~~-</li>~~
-</ul><h4>Clinical presentation</h4><p>Perforation of the uterus at the time of insertion may be clinically silent or cause significant pelvic pain. A late perforation may be asymptomatic, or present with non-specific lower abdominal pain. In all cases, the visible 'strings' will be missing at direct inspection. Peritoneal sepsis is a rare presentation.</p><h4>Pathology</h4><p>IUCD-related uterine perforation ranges from embedment in the myometrium to complete transuterine perforation with a migration of the intrauterine contraceptive device into the peritoneal cavity <sup>6</sup>.</p><p><a href="/articles/embedded-intrauterine-contraceptive-device">Embedment</a> refers to the penetration of an intrauterine contraceptive device into the endometrium or myometrium without extending through the serosa.</p><p>Intra-abdominal migration occurs when the intrauterine contraceptive device is freely floating in the abdomen or pelvis encased in <a href="/articles/abdominal-adhesions">adhesions</a> or adherent to bowel or the omentum. Adhesions can lead to <a href="/articles/infertility">infertility</a>, chronic pain, and <a href="/articles/bowel-obstruction">intestinal obstruction</a> <sup>6</sup>.</p><h4>Radiographic features</h4><p>Ultrasound is the recommended first-line investigation <sup>3</sup> in all women in whom the ‘strings’ cannot be visualised. Orthogonal radiographs are often the second line. CT can be used in complex cases where visceral involvement or surgical difficulty is suspected.</p><h5>Plain radiograph</h5><ul><li>an intrauterine contraceptive device lying lateral to midline may suggest the diagnosis</li></ul><h5>Ultrasound</h5><ul>
~~-<li>may have a normal endometrial cavity on ultrasound</li>~~
~~-<li>hyperechoic linear structure lying outside the uterus</li>~~
-</ul><h4>Treatment and prognosis</h4><p>Treatment depends on the degree of perforation and whether there are any complications (such as peritoneal sepsis or intestinal obstruction).</p><h4>See also</h4><ul><li><a href="/articles/embedded-intrauterine-contraceptive-device">embedded intrauterine contraceptive device</a></li></ul>
+<li><p>atrophic/postpartum uterus</p></li>
+<li><p>uterine structural abnormalities <sup>5</sup></p></li>
+<li><p>large <a href="/articles/uterine-leiomyoma">fibroids</a> <sup>5</sup></p></li>
+</ul><h4>Clinical presentation</h4><p>Perforation of the uterus at the time of insertion may be clinically silent or cause significant pelvic pain. A late perforation may be asymptomatic, or present with non-specific lower abdominal pain. In all cases, the visible "strings" will be missing at direct inspection. Peritoneal sepsis is a rare presentation.</p><h4>Pathology</h4><p>IUCD-related uterine perforation ranges from embedment in the myometrium to complete transuterine perforation with a migration of the intrauterine contraceptive device into the peritoneal cavity <sup>6</sup>.</p><p><a href="/articles/embedded-intrauterine-contraceptive-device">Embedment</a> refers to the penetration of an intrauterine contraceptive device into the endometrium or myometrium without extending through the serosa.</p><p>Intra-abdominal migration occurs when the intrauterine contraceptive device is freely floating in the abdomen or pelvis encased in <a href="/articles/abdominal-adhesions">adhesions</a> or adherent to bowel or the omentum. Adhesions can lead to <a href="/articles/infertility">infertility</a>, chronic pain, and <a href="/articles/bowel-obstruction">intestinal obstruction</a> <sup>6</sup>.</p><h5>Aetiology</h5><p>Uterine perforation is thought to be related to low oestrogen levels leading to uterine shrinkage.</p><h4>Radiographic features</h4><p>Ultrasound is the recommended first-line investigation <sup>3</sup> in all women in whom the "strings" cannot be visualised. Orthogonal radiographs are often the second line. CT can be used in complex cases where visceral involvement or surgical difficulty is suspected.</p><h5>Plain radiograph</h5><ul><li><p>an intrauterine contraceptive device lying lateral to midline may suggest the diagnosis</p></li></ul><h5>Ultrasound</h5><ul>
+<li><p>may have a normal endometrial cavity on ultrasound</p></li>
+<li><p>hyperechoic linear structure lying outside the uterus</p></li>
+</ul><h4>Treatment and prognosis</h4><p>Treatment depends on the degree of perforation and whether there are any complications (such as peritoneal sepsis or intestinal obstruction).</p><h4>See also</h4><ul><li><p><a href="/articles/embedded-intrauterine-contraceptive-device">embedded intrauterine contraceptive device</a></p></li></ul>

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IUCD-related uterine perforation

Updates to Article Attributes

Epidemiology

Aetiology

Risk factors

Associations

Clinical presentation

Pathology

Aetiology

Radiographic features

Plain radiograph

Ultrasound

Treatment and prognosis

See also