Migration of an intrauterine device into the bladder: a rare case

Arch Gynecol Obstet (2009) 279:739–742 DOI 10.1007/s00404-008-0792-3 C A S E RE P O RT Migration of an intrauterine device into the bladder: a rare case Umur Yensel · Incim Bezircioglu · Ali Yavuzcan · Ali Baloglu · Burcu Cetinkaya Received: 7 July 2008 / Accepted: 28 August 2008 / Published online: 17 September 2008  Springer-Verlag 2008 Abstract Introduction Intrauterine device (IUD) application has been used for over 30 years and is a widely accepted contraception method among women because of its lowcomplication rates. The use of intrauterine devices may cause complications but migration of the IUD into an adjacent organ is rarely encountered. Case In the present report, we present a 26-year-old patient to whom IUD had been applied 2 years ago and whose examination performed due to pain and urinary complaints revealed migration of the uterine device into the bladder. Conclusion Patients with pelvic pain and chronic irritative urinary symptoms whose vaginal examination and ultrasonography reveal a dislocated IUD should be carefully examined for the migration of the IUD into the bladder. In order to avoid this rare complication, patient should be evaluated physically and ultrasonographically for uterine position, thinness of the uterine wall and inXammatory disease before the insertion. The patient should be U. Yensel · I. Bezircioglu · A. Yavuzcan (&) · A. Baloglu · B. Cetinkaya 1st Department of Obstetrics and Gynecology, Izmir Ataturk Training and Research Hospital, 35820 Izmir, Turkey e-mail: [email protected] U. Yensel e-mail: [email protected] I. Bezircioglu e-mail: [email protected] A. Baloglu e-mail: [email protected] B. Cetinkaya e-mail: [email protected] evaluated with sonography immediately after insertion and periodically. Keywords Bladder · Intrauterine device · Migration Introduction Intrauterine device (IUD) application has been used for over 30 years and is a widely accepted contraception method among women because of its low-complication rates [1]. The use of intrauterine devices may cause complications, such as pelvic abscess, uterine rupture and septic abortion. The incidence of uterine perforation is 1–3 in 1,000 applications [2]. However, the migration of the IUD into an adjacent organ is rarely encountered. In the present report, we present a 26-year-old patient to whom IUD had been applied 2 years ago and whose examination performed due to pain and urinary complaints revealed migration of the uterine device into the bladder. The case A 26-year-old patient to whom IUD had been applied 2 years ago was admitted to our hospital with complaints of pelvic pain and urinary system infections. The vaginal examination revealed that the IUD was dislocated. Urinalysis and all other laboratory Wndings including a complete blood count and blood biochemistry proWle were within normal levels. There were no data to support tendency of urolithiasis. Pelvic ultrasonography revealed hyperecogenity in the bladder wall, which might be consistent with IUD. Intrauterine device was detected in the pelvis via direct pelvic radiography examinations. Pelvic computed 123 740 Arch Gynecol Obstet (2009) 279:739–742 tomography revealed that the IUD was in the upper front part of the bladder and no pathologies were determined in the pelvic genital structures (Fig. 1). No pathological Wndings were established in the abdomen ultrasonography and intravenous pyelography. Cystoscopic examination revealed no evidence of intravesical migration of the IUD, so the patient underwent suprapubic exploration. During the observation, pervasive adhesions were seen between the urinary bladder fundus and the omentum. After the removal of the adhesions with sharp dissection, the IUD, which had sunk into the muscular layer of the bladder, was exposed and removed (Figs. 2, 3). It was determined that the IUD strings were calciWed in the bladder and they were slowly excised from the bladder. The cut in the bladder measuring 0.3 cm was repaired. The bladder was Wlled with approximately 250 cc of isotonic Fig. 3 The removal of the intrauterine device from the bladder NaCl and leakage was not observed. After the bleeding test, a drain was inserted and the operation was concluded. No complications occurred in the postoperative period and the patient was discharged on the 7th day. Discussion Fig. 1 The intrauterine device in the upper-front part of the bladder revealed by computed tomography Fig. 2 The intrauterine device that had sunk into the muscular layer of the bladder 123 There are about 110 case reports published about the migration of IUDs outside the uterine cavity. In about 80 of these cases, the IUDs were located in the bladder with or without they being calciWed. If the IUD strings cannot be observed during the vaginal examination and the IUD cannot be detected via ultrasonography, IUD dislocation should be considered. In such cases, direct pelvic radiography examination should be performed initially for diagnosis. With this procedure, it is determined whether the IUD is inside the pelvis or not. Thus, the IUDs that migrate intravesically after bladder trauma can be easily demonstrated. Although transvaginal sonography is a perfect method for the visualization of the uterus and the ovaries, it may prove inadequate in the evaluation of the lesions in the front section of the bladder as in our case. The abdominopelvic sonographic examination, on the other hand, is very eVective in the detection of an intravesical migrated IUD [3]. Overlooked uterine perforations, spontaneous uterine contractions, irregular contractions of the bladder, intestinal motility and peritoneal Xuid movement may explain the migration of an IUD outside the uterine cavity [4]. If the IUD has migrated into the bladder, its metal parts cause calcium precipitation, which is followed by calculus formation in a short while [5]. Arch Gynecol Obstet (2009) 279:739–742 Inept insertion and position, fragile uterine wall and sepsis are some of the factors associated with uterine perforation and subsequent transvesical migration [6]. For preventing such inadvertent uterine perforations, patient should be evaluated physically and ultrasonographically for uterine position, thinness of the uterine wall and inXammatory disease before the insertion. Generally the operator cannot disqualify whether the uterine perforation occurred at insertion. So the patient should be evaluated with sonography, immediately after insertion and periodically thereafter. The patients may be asymptomatic but they may apply to health centers with various complaints of urinary system irritation. As a result of the erosion in the bladder, hematuria, lower abdominal pain and recurrent urinary system infections may develop. Dietrick et al. [7] has shown that the patients whose IUDs migrate intravesically demonstrate symptoms of urinary system disorders for a period of 3–60 months. IUD was applied 2 years ago to the patient introduced in this report, whereas her complaints have been present for a year. The IUD that dislocates into the bladder should be removed due to the potential complications and the symptoms it causes. Also the current accepted management is removal of the device from the abdominal cavity in order to prevent further morbidity [8]. Cystoscopy or suprapubic cystotomy can be used for treatment [2, 9]. As for our case, the IUD, which was found to be partly sunk into the muscular layer, was removed via simple excision after the cleavage between the bladder and the uterus was located. Markovitch et al. [10] proposed that the surgical treatment criteria in cases of IUD dislocation following uterine perforation should be reconsidered. They also claimed that the IUD should be removed with surgical procedures in symptomatic patients, however, asymptomatic patients may beneWt from conservative treatment methods under appropriate conditions. In such cases, patients generally develop adhesions due to recurrent sepsis and urinary tract infection. Genitourinary Wstulas may be seen. So in order to avoid genitourinary Wstulas, minimally invasive endourological management should be preferred. Endoscopic retrieval of migrant IUD is the preferred option. In the cases with the IUDs found completely inside the bladder, cystoscopic extraction of the device and the stones were successful without complications, the tiny hole created between bladder and uterine wall will close after few days of bladder drainage by a Foley catheter. On the other hand, in the case with partial penetration of the bladder wall, open surgery was utilized to retrieve the device and repair the defect [11], similar to our case. There is a real need to optimize surgical treatment of displaced IUDs due to increase in morbidity from extensive open surgical explorations. Also 741 patient expectations necessitate treatment by the least invasive procedure that is, endoscopically [12]. Our case was a case of missed IUD uterine perforation, the patient being symptomatic for 1 year, which was detected after 2 years. After the treatment, genitourinary Wstulas might be seen. The presenting complaints of genitourinary Wstulas are permanent, total and isolated urinary incontinence, partial urinary incontinence associated with menstrual hematuria, vesical menstrual bleeding associated with oligomenorrhoea and menouria [13]. But our patient had no complaints at the end of the 21-month follow-up. Patients with pelvic pain and chronic irritative urinary symptoms whose vaginal examination and ultrasonography reveal a dislocated IUD should be carefully examined for the migration of the IUD into other intra-abdominal organs, particularly the bladder. In the present case, the localization of the IUD, which was easily detected via direct radiography due to the calciWcation around it, was determined using computed tomography. The present case also emphasizes that a simple radiographic examination in the evaluation of a patient with an IUD may be enough, due to the calciWcation around it. However, advanced imaging methods and cystoscopic evaluations are needed for the case which has no stone formation round the IUD [14]. Ultrasonography will only help in early detection not prevention of this complication, because perforation and migration outside the uterine wall in to adjacent organs may have already occurred. References 1. Demirci D, Ekmekcioglu O, Demirtas A, Gulmez I (2003) Big bladder stones around an intravesical migrated intrauterine device. Int Urol Nephrol 35:495–496. doi:10.1023/B:UROL.0000025624. 15799.8d 2. Zakin D, Stern WZ, Rosenblatt R (1981) Complete and partial uterine perforation and embedding following insertion of intrauterine devices. II. Diagnostic methods, prevention, and management. Obstet Gynecol Surv 36:401–417 3. MahmutyazÂcÂoglu K, Ozdemir H, Ozkan P (2002) Migration of an Ântrauterine contraceptive device to the urinary bladder: sonographic Wndings. J Clin Ultrasound 30:496–498. doi:10.1002/ jcu.10098 4. 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