Mustafa Burak Hoşcan md, Hýzýrbey mah, Karakol sok, Görgülü apt., A blok K:2 D:732100 Isparta, Turkey. Email: firstname.lastname@example.org
Abstract Spontaneous migration of an intrauterine device into the bladder is very rare. A 29-year-old woman in whom an intrauterine device had been placed 6 years previously, presented complaining of chronic pelvic pain and recurrent irritative urinary tract symptoms. One year after insertion she had became pregnant and given birth without complications. Intravesical migration of the intrauterine device was confirmed by sonography and cystoscopy. The intrauterine device was removed by suprapubic cystostomy.
The intrauterine device (IUD) has been plagued by many complications, including uterine perforation, septic abortion, pelvic abscess, ectopic pregnancy and migration into adjacent organs.1–3 Perforation of the uterus and migration of IUD into the adjacent soft tissues are infrequent complications of the use of these devices. We report a case in which 6 years elapsed between insertion and removal of an IUD without stone formation in the urinary bladder.
A 29-year-old woman was admitted to our clinic with a 5-year history of recurrent pain on voiding, urgency, frequency and chronic pelvic pain. She had had these symptoms about five to six times per year. She had never complained of vaginal bloody discharge. Physical examination was normal, including digital vaginal examination. Urinalysis revealed five to six leukocytes and six to seven erythrocytes per high power field, but a urine culture remained sterile. All other laboratory findings including a complete blood count, blood biochemistry profile and C-reactive protein were within normal levels. As noted from the patient's medical history, an IUD had been inserted in 1998. Unexpectedly, she had became pregnant 1 year later, and had given birth without complications just before the onset of her symptoms. The IUD had not been recovered and it was assumed that it had fallen out. She had been treated empirically for urinary tract infection several times by different general practitioners without proper investigation by urinary tract imaging and cystoscopy. When she applied to our clinic, it was the first time she was seen by a urologist.
A plain abdominal radiograph showed a 1 cm diameter opacity in the pelvis overlying the IUD (Fig. 1). Sonographic evaluation of the bladder showed that the IUD was in the bladder (Fig. 2). Cystoscopy revealed that the IUD was penetrating the posterior wall of bladder and was fixed to the bladder wall, not lying free in the bladder. We removed the IUD by suprapubic cystostomy (Fig. 3). The IUD was partially embedded in the muscular wall of the bladder. Interestingly, there was no stone formation round the IUD. The patient tolerated the procedure well, and was discharged from the hospital 7 days postoperatively.
The IUD has great acceptance among many women, and has been in use for many years with a low complication rate. The most serious complication of this method of contraception is perforation of the uterus and migration into adjacent organs.3–6 The incidence of uterine perforation ranges from 1 to 3 per 1000 insertions.7 Intravesical migration is a rare complication and it is usually symptomatic, causing pelvic pain and irritative voiding symptoms.1 These devices can get encrusted with deposits forming calculus. However in our patient there was no stone formation around the IUD. The interval between insertion and symptoms varies from 6 months to 16 years.3
Findings in our patient suggest that uterine perforation may be at insertion or delayed perforation. Uterine perforation by an IUD may depend on the operator's experience, the design of the device or the thinness of the uterine wall.8 As we can not rule out whether the uterine perforation occurred at insertion, we suggest evaluating the patient with sonography immediately after insertion and periodically thereafter. The follow up with sonography also enables us to detect undesired pregnancies.
Although controversy in the management of the migrating IUD in asymptomatic patients still persists, it appears to be a consensus that all extrauterine copper-laden devices should be removed because of the increased inflammatory reaction they induce. A migrated IUD in the bladder must be removed because of its complications. This can be accomplished by cystoscopy as reported previously.4,7 It can also be removed by suprapubic cystotomy, especially when the IUD is fixed to the bladder wall.1,2,5
Chronic pelvic pain and irritative voiding symptoms with a history of an unretrieved IUD must be carefully researched for possible intravesical migration. The present case also emphasizes that a simple radiographic examination in the evaluation of a patient with an IUD may not be enough, especially when there is no stone formation round the IUD. The IUD that has partially embedded in the muscular wall of the bladder can be removed either by suprapubic cystotomy or cystoscopy.