IUCD as bladder stone

Introduction

Intrauterine Contraceptive Devices (IUCDs) are amongst the most commonly used forms of long-acting reversible contraceptives (LARCs) in low to middle-income countries. Although IUCDs have high efficacy, are safe and cost-effective, they are associated with various short and long term complications such as intrauterine infection, abnormal uterine bleeding, sepsis, ectopic pregnancy amongst others. ¹ Uterine perforation with the migration of IUCD into adjacent organs can occur either at the time of insertion (primary perforation) or unforced spontaneous perforation (secondary perforation),^1,2 but is exceptionally rare, though important to exclude.^3,4

Case report

A 55-year-old para three post-menopausal female, who had had three previous vaginal deliveries, presented to our gynecology clinic with complaints of lower abdominal pain, intermittent urinary frequency and burning over the previous six months., during which five episodes of urinary tract infection (UTI) had been treated. A current infection with Eschericia coli was confirmed. On account of her recurrent UTIs, further investigations were carried out; a pelvic radiograph revealed the presence of a dense solitary radio-opaque structure within the bladder suggestive of an intravesical calculus having a T-shaped extension from it (Figure 1).

OPEN IN VIEWER

Figure 1.

Pelvic radiograph showing a dense solitary radio-opaque structure within the bladder suggestive of an intravesical calculus along with a T-shaped extension from it (black arrow).

Our patient revealed a past history of IUCD insertion after her last vaginal delivery 25 years previously; this had never been removed. No IUCD thread could be seen on speculum examination, and transvaginal ultrasonography revealed a normal post-menopausal size uterus with thin endometrium and normal ovaries. No intrauterine IUCD was seen. However, a hyperechoic 35 mm intravesical calculus was visualized.

Cystoscopy was performed for further evaluation. This confirmed the presence of a large solitary bladder stone encasing an encrusted IUCD. Cystolithotripsy was performed with a Holmium-YAG laser, fragmenting the calculus, which separated from the IUCD (Figure 2), which could then readily be removed intact with its two attached threads using forceps (Figure 3). The bladder wall was intact with no current evidence of vesico-uterine fistula. Treatment with oral levofloxacin 500 mg for 10 days was given as determined by the urine culture sensitivity report, following which she was discharged two days later. She remained symptom-free at her one-month follow-up visit.

OPEN IN VIEWER

Figure 2.

Cystoscopy image showing fragmented bladder calculus with a migrated IUCD within the bladder.

OPEN IN VIEWER

Figure 3.

Intact IUCD with the fragmented calculus removed using cystoscopy forceps.

Discussion

Proper patient counselling prior to IUCD insertion is mandatory. Serious late complications resulting in uterine perforation are rare, but not unheard of. The IUCD may migrate through the uterine mucosa, into the myometrium, out into peritoneal cavity and into an adjacent viscus. ⁵

Such migration may occur acutely, particularly if the uterine wall is thin; secondary migration is usually associated with genital infection, previous uterine surgery, or genital trauma. ¹ The former may be provoked by partial or complete uterine perforation occurring at the time of insertion, and thus is more common with a scarred, retroverted or hyper-anteverted, bifid or septate uterus. ⁶

A migrated IUCD may have varied clinical presentations. ⁷ It may be an incidental finding in an asymptomatomatic patient. In the bladder it acts as a foreign body causing lower urinary tract symptoms such as urgency, frequency or hematuria. ⁸ It predisposes to intravesical calculus formation and recurrent urinary tract infections. Therefore, IUCD displacement must be kept in mind as a differential in female patients presenting with a ‘lost’ IUCD, especially when IUCD strings cannot be seen in the vagina.^1,2 The presence of a vesicouterine fistula may be ruled out by a dye test. ⁸ Neglected IUCDs must be removed wherever they are, as subsequent infection is almost inevitable. Removal may prove difficult. ⁹

A safe proper insertion method for IUCDs is obligatory. Patients should check for missing threads to aid in the early diagnosis of a migrated IUCD. Follow-up is essential.^10,11 IUCDs need to be removed once their duration of action is completed or they are no longer required by the patient, particularly in menopausal females.

Conclusion

IUCDs require regular evaluation to confirm their correct position. Health care professionals, especially gynecologists, must be aware of the rarer long term complications of IUCDs so that proper patient counselling can be done and the incidence of forgotten IUCDs can be minimized. That being said, urologists also need to be aware of these cases so that gynecological history is kept in mind while evaluating females with urinary symptoms. Serious complications such as intravesical migration are extremely rare but still possible. An increase in the cesarean delivery rates, along with increased awareness about contraception leading to increase in the use of IUCDs translates to a potentially increased incidence of migrated IUCDs in the coming years.