Laparoscopic management of rectal perforation caused by a migrated intrauterine device with a coexisting intrauterine device: a case report

Migration of an intrauterine device (IUD) into the rectum is a rare but potentially life-threatening complication. The coexistence of two IUDs, one normally positioned and one that has silently migrated, is even more exceptional and poses a significant diagnostic challenge, because an ectopic device may be repeatedly missed on routine ultrasound and mistaken for spontaneous expulsion. A 47-year-old woman (gravida 4, para 2) presented with a one-month history of loose stools without abdominal pain or rectal bleeding. Her first IUD (Mutile), inserted more than 20 years earlier, was presumed to have been expelled; a second device was later removed for vaginal bleeding, and a third device (AiMu), placed approximately 10 years earlier, was considered correctly positioned. Colonoscopy revealed a black metallic foreign body embedded in the rectal wall 10 cm from the anal verge with surrounding abscess formation, and computed tomography confirmed a metallic density in the mid-lower rectum 66 mm from the anal verge. Pelvic ultrasound demonstrated the dual-IUD configuration. The patient underwent combined hysteroscopic and laparoscopic surgery: the normally positioned AiMu device was removed hysteroscopically, and the migrated Mutile device was retrieved laparoscopically, followed by primary repair of a 1.0 × 0.3 cm anterior rectal perforation and a protective terminal ileostomy. She recovered uneventfully and was discharged on postoperative day 7. The stoma remained healthy and functional during follow-up, and the protective ileostomy was successfully reversed three months after the initial surgery. This case highlights that failure to visualize an IUD on ultrasound does not confirm expulsion. When device localization remains uncertain or extrauterine migration is suspected, computed tomography is an appropriate modality to clarify the situation before assuming spontaneous expulsion and placing a new device, in order to avoid the accumulation of multiple devices and delayed recognition of visceral migration.