the intrauterine device ( iud ) was a very common form of birth control in the united states . uterine perforation is common among women with  lost  iuds and can cause severe morbidity and mortality and should be carefully managed . this can usually be managed laparoscopically unless bowel perforation or other severe sepsis is present . an intra - abdominal iud was removed laparoscopically from the perirectal fat of a 49-year - old women who had been diagnosed over 20 years earlier with an  expelled  iud . it is important that the possibility of uterine perforation be considered in anyone who has had a diagnosis of an expelled iud without actual confirmation that the iud is no longer present in the body . in any woman who presents with pelvic pain and a history of a  lost  iud it may be advisable to question women about possible iud use when they present with pelvic pain of unknown origin . the intrauterine device ( iud ) has fallen out of favor in the united states , with less than one percent of american women now using an iud for contraception . however , in the 70s and early 80s , iuds were in frequent use . since patients depend on medical personnel for removal of this contraceptive device , there are probably a number of women who still may have iuds in place . in the absence of the sexually transmitted agents of salpingitis , iuds are very safe and effective contraceptives , with rare complications . however , they can cause severe morbidity and mortality and , therefore , should be actively managed . unfortunately , expulsion is often the diagnosis when the iud string is not visible without careful determination of what has actually happened to the iud . a perforated iud can remain in the abdomen for years until the onset of more serious symptoms occurs . the recommended treatment for perforation of the uterus by an iud is removal of the iud . this can usually be managed laparoscopically unless bowel perforation or other severe sepsis is present . a 49-year - old gravida 5 para 3 abortus 2 woman presented with severe chronic pelvic pain and deep dyspareunia . no evidence of endometriosis was found , and the uterus , ovaries and tubes were within normal limits . the rectosigmoid colon was found to be adherent to the cul - de - sac . when those adhesions were separated , an intrauterine device of the lippes loop type was found imbedded in the perirectal fat ( figure 1 ) . she had gone to a different doctor a week later and had been told that she must have expelled the device . however , the first incidence of right lower quadrant and pelvic pain of unknown origin listed in the patient 's available records occurred 21 years before the surgery , several years after she estimated that her iud was placed . the iud was a prevalent form of birth control in the united states and is still frequently used in other countries . its use has declined in the united states in part because of litigation surrounding a specific iud , the dalkon shield ; this iud had a strong association with pelvic inflammatory disease ( pid ) , thought to be due to its multifilament tail . however , the newer iuds are not associated with pid in the absence of sexually transmitted agents and are an effective form of birth control . they are relatively inexpensive per unit time and require minimal compliance by the patient to remain effective . . however , they do not protect the user from sexually transmitted diseases ( stds ) . when iud types have been compared , no significant difference was found between rates of perforation . uterine perforation most often is symptomless and is first suspected when the woman presents with unintended pregnancy or for removal of the iud , and the strings can not be located . it is speculated that most perforations occur at the time of insertion , although some have proposed that perforations can arise secondarily as well . most investigators believe , however , that the perforation must at least start at insertion . most perforations , fortunately , are uncomplicated . however , adjacent organs may become involved . if bowel strangulation and perforation occurs , the situation can quickly become life - threatening . displaced iuds have been known to penetrate the different organs of the pelvis , with the most commonly reported site of perforation being the colon . the bladder and the small bowel are other sites of perforation that can be life threatening . very often in the past , a missing iud string was simply diagnosed as an unnoticed expulsion , and no further follow - up was done . every case of missing iud strings should be carefully followed up to exclude perforation as the cause , and the diagnosis of expulsion should never be made unless the physician has physical evidence ( ie , the actual iud , or a film showing no evidence of an iud within the body ) that the iud is no longer present in the body . if this had been standard practice , some severe complications may have been prevented . in our case , greater than 20 years elapsed from the time the patient was diagnosed with expulsion and her treatment . a long duration of time between evidence of perforation and development of significant symptoms is not uncommon . because iuds can be loose in the pelvis for long periods without causing complications , and often cause no complications at all , in the past , it has been recommended that open iuds not be removed unless complications ensue . however , more recently , the recommendation has been made that all perforated iuds should be removed because of the severe morbidity and mortality that late complications may cause . in this particular case , since there was no history of a lost iud prior to the laparoscopy for pelvic pain , no specific evaluation for a  lost  iud was undertaken . the usual evaluation for a patient presenting with nonvisible or nonpalpable iud strings is to first probe the endocervical canal to see if the strings can be brought down with a cotton - tipped applicator . if there has been missed or irregular menses , a pregnancy test should be done . if the strings can not be brought down , in most cases pelvic ultrasound will identify the iud in the endometrial cavity . if there is a question as to whether the iud is partially embedded in the uterine wall , sonohysterography or hysteroscopy may be performed next . if , however , ultrasound is unsuccessful in locating the iud , a flat plate and upright of the abdomen should be performed to look for an extrauterine location of the iud . in the case of an extrauterine iud , surgical removal is indicated . in removing an embedded iud from the endometrial cavity with a grasping instrument or by hysteroscopy , prophylactic antibiotics should be considered . also , when doing a laparoscopy for an intra - abdominal iud , prophylactic antibiotics are recommended . in this case , it is possible that the patient may have been saved many years of pain if the perforation had been diagnosed at the time it occurred . it is important that the possibility of uterine perforation be considered in anyone who has had a diagnosis of an expelled iud without actual confirmation that the iud is no longer present in the body . in any woman who presents with pelvic pain and a history of a  lost  iud , it may be advisable to question women about possible iud use when presenting with pelvic pain of unknown origin .
background : the intrauterine device ( iud ) was a very common form of birth control in the united states . 
 the most serious potential complication of iud use is uterine perforation . 
 uterine perforation is common among women with  lost  iuds and can cause severe morbidity and mortality and should be carefully managed . 
 the recommended treatment is removal of the perforating iud . 
 this can usually be managed laparoscopically unless bowel perforation or other severe sepsis is present.methods:an intra - abdominal iud was removed laparoscopically from the perirectal fat of a 49-year - old women who had been diagnosed over 20 years earlier with an  expelled 
 iud.conclusions:it is important that the possibility of uterine perforation be considered in anyone who has had a diagnosis of an expelled iud without actual confirmation that the iud is no longer present in the body . in any woman who presents with pelvic pain and a history of a  lost  iud 
 , the surgeon should have a high index of suspicion and obtain radiological studies . 
 it may be advisable to question women about possible iud use when they present with pelvic pain of unknown origin .