- Email: [email protected]
INTRAVESICAL MIGRATION OF AN INTRAUTERINE DEVICE (IUD)
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INTRAVESICAL MIGRATION OF AN INTRAUTERINE DEVICE (IUD) Dr. Andreas P. Christodoulides , Dr. Theocharis Karaolidis MD, Phd, FEBU PII: DOI: Reference:
S0090-4295(20)30186-2 https://doi.org/10.1016/j.urology.2020.02.009 URL 21993
To appear in:
Urology
Received date: Revised date: Accepted date:
15 January 2020 27 January 2020 5 February 2020
Please cite this article as: Dr. Andreas P. Christodoulides , Dr. Theocharis Karaolidis MD, Phd, FEBU , INTRAVESICAL MIGRATION OF AN INTRAUTERINE DEVICE (IUD), Urology (2020), doi: https://doi.org/10.1016/j.urology.2020.02.009
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
TITLE PAGE/Acknowledgments INTRAVESICAL MIGRATION OF AN INTRAUTERINE DEVICE (IUD) AUTHORS First Author a) Dr. Andreas P. Christodoulides Urology Resident Nicosia General Hospital, Cyprus. Email: [email protected] Postal Address: Leoforos Larnakos 71, aprtm 102, Nicosia, Cyprus, 1046 Telephone number: 0035799337988
Corresponding Author b) Dr.Theocharis Karaolidis MD, Phd, FEBU, Urologist Nicosia General Hospital, Cyprus. Email: [email protected] Postal address: Nicosia General Hospital, Nicosia-Limassol Old Road, No.215, Strovolos, 2029, Nicosia, Cyprus. Telephone number: 0035722604398
KEYWORDS IUD, Gynecology, Urology, Coil, Case Report, Migration
ABSTRACT Intrauterine devices(IUD) are used by women worldwide as the most conventional method of reversible contraception. Migration of an IUD to pelvic or abdominal organs is considered rare. We report a case of a 67 year old female who had neglected to remove her IUD for 20 years. She visited our clinic because of recurrent UTI’s the previous year. After assessment and clinical investigation it was found that the coil had a late onset migration to the urinary bladder, with calculus formation, causing the patients’ symptoms. In our case we cystoscopically removed the encrusted coil after performing endoscopic cystolitholapaxy. The patient had an uneventful recovery and her UTI’s subsided. The objective of this article is to report the first case of intravesical IUD migration at our clinic and raise awareness of forgotten contraceptive devices and their potential complications.
INITIAL PRESENTATION A 67-year-old female was evaluated at Urology outpatient offices in August 2019. She suffered from worsening recurrent urinary tract urgency for the last year. She also had long term symptoms that included, dysuria, pelvic pressure, suprapubic and pelvic pain. The patient was sexually active without dyspareunia. She was initially diagnosed with urinary infection by her obstetrician (OB) 4 months earlier. However, after recurrence of the UTI further investigation was performed. The organisms causing her last UTIs were E.coli and enterococcus spp. The patient claimed to have suffered three urinary infections the past six months which were treated with antibiotics by her general practitioner. She mentioned that she had sporadic infections long-term but had no documents to confirm this claim. An x-ray was performed mostly in order to exclude spinal origin of the pain and this revealed a calcified opacity 3-4cm at the minor pelvis. [figure 1] A urological ultrasound confirmed the presence of stone in the urinary bladder. At the time there was no suspicion of a coil and a possible migration to an adjacent organ. She mentioned that she had had an IUD inserted around 20 years ago after her second c-section but had forgotten to remove it. Unfortunately, she didn’t recall the time of insertion. At the office, pelvic examination was normal. No visible strings coming out through the vaginal canal. Urine presented cloudy. Urine culture revealed infection by e.coli once again. Blood tests confirmed normal renal function. Her medical history included 2 caesarean sections (1982, 1986) and atrial fibrillation under Xarelto. She had no history of urolithiasis. She didn’t receive any form of imaging after the insertion of the IUD until her visit to the urology outpatient offices. Abdominopelvic
ultrasound at the office revealed a radio-opaque structure in the bladder. [figure 2] Kidneys and other internal organs were without pathological findings. The patient was then scheduled for endoscopic investigation which was performed a few days later. Rigid cystoscopy showed an encrusted, free-floating intravesical foreign body consistent with a heavily calcified IUD. Bladder wall was normal and didn’t show any signs of embedding, erosion or scarring. The patient was soon arranged for cystolitholapaxy and removal of the coil [figure 3] under anesthesia. Urethral Foley catheter was kept post-op for two days. The patient had an uneventful recovery. Her recurrent UTIs subsided and remained asymptomatic on her follow up a month later. DISCUSSION by Dr.Theocharis Karaolides MD, Phd, FEBU Several kinds of foreign bodies have been found inside urinary bladders. The literature reports an extended list including urethral dilators, wires, surgical appliances, coffee spoon handles, cables. The usual access route is via the urethra, frequently by self-introduction or in the interim of a transurethral surgical procedure. Infrequently, these objects are placed during an open or traumatic surgical process. Rarely, they can drift from a neighboring anatomical structure. [6,7] There have been several reports of intrauterine devices migrating to the urinary bladder. [1,2,3,6] An intrauterine device, also known as intrauterine contraceptive device (IUCD or ICD) or coil, is a small, often T-shaped birth control device that is inserted into a woman's uterus to prevent pregnancy. IUDs are one form of long acting
reversible birth control (LARC). [8] It has high efficacy and low complication rates and is used on over 100 million women. [1,7,9] Late complications of these devises include among others uterine perforation, malignant transition [10] and migration into neighboring structures. [11,12,13] Possible sites of IUD migration are to the bladder (intravesical), peritoneum, omentum, rectosigmoid, appendix, small bowel, colon, adnexa and iliac vein. [1,2,6] Possible complications vary from mild discomfort to more severe symptoms depending on the site of the misplacement of the IUD. Complications may include sepsis, septic abortion, ectopic pregnancy, pelvis abscess, peritonitis, appendicitis, bowel obstruction, bowel perforation, obstructive nephropathy, infertility (due to intraperitoneal adhesions), vesicouterine fistula, pulmonary embolism and death. In our case there were no symptoms related to the displacement itself and this leaves the time that the migration occurred unknown. Symptoms appeared after the coil was encrusted in the urinary bladder. This is not uncommon. Such cases can accidentally be discovered during imaging for another reason or due to the development of lower urinary symptoms.[6] The mechanism that causes uterine perforation as a result of migration or misplacement of an IUD is not completely acknowledged. Many risk factors are associated with uterine perforation. These include congenital uterine anomalies, uterine thickness, uterine position and consistency, time of insertion (first three months after delivery), past pelvic surgeries, genital infections and the applicators experience. [1,7,8,14] These factors should be regarded to with precaution and IUD insertion should be avoided when possible.
An example of unforced spontaneous perforation of the uterus and intravesical migration of an IUD is presented in our case. This is very rare with an incidence of 0.12-0.68/1000 insertions.[1] The possible mechanisms which are reported in the literature are presented on Table 1. Uterine perforation can be partial or complete, depending on if the IUD has passed completely through the uterine wall or not.[2] It is considered that calculus forms on the IUD after the device migrates to the bladder. [11,15] The time interval between insertion and symptoms varies from 6 months to 16 years, unless the patient presents with acute symptoms. In our case the patient presented with dysuria and recurrent UTIs after 20 years of insertion. It is not possible to know when the IUD migrated into the urinary bladder. However, this must be related to the appearance of her urinary tract infections almost one year before she was referred to us. It is well known that women with recurrent UTIs (≥2 infections in six months or ≥3 infections in one year) should undergo further investigation. One of the rare reasons of recurrent UTIs is foreign bodies in the urinary bladder. A combination of lower urinary tract symptoms and a history of an unretrieved IUD should set the suspicion of potential perforation of the uterus and intravesical migration/mislocation. When IUD strings are not inspected in the vagina during examination and are not detected in the endometrial cavity using ultrasonography, a physician must contemplate IUD displacement.
In addition, bladder stones are an unusual finding in female patients, which should raise skepticism of the presence of a foreign body in the bladder. All extrauterine copper-laden devices should be removed, as copper IUDs result in inflammatory reactions and adhesions. The World Health Organization (WHO) and the International Medical Advisory Panel Meetings of the International Planned Parenthood Federation recommend that an IUD displaced from the uterine cavity should be removed as soon as possible after diagnosis, regardless of its type and location. Whilst surgical procedures to remove a misplaced IUD must be performed on symptomatic patients, asymptomatic patients, under certain circumstances, may favor from conservative management. [12] Treatment options for intravesical IUDs differ. IUDs that are situated fully in the bladder, with or without small calculi, can be retrieved by cystoscopic or suprapubic cystoscopic extraction. Laparoscopic surgery or open surgery can be used for the removal of coils with big stone development or with fractional invasion of the bladder wall [13]. Consequently, treatment options for displaced IUDs must be chosen carefully because of the increase in morbidity by open surgery and because of patient preferences for least invasive procedures. Pre-operative assessment may include axial imaging CT scan or endoscopic evaluation with cystoscopy. In the present case we removed the IUD cystoscopically after manual stone lithotripsy with no further complications.
CONCLUSIONS Recurrent urinary tract infections should trigger further investigation. Gynecological history should be included in this procedure. A history of an unretrieved IUD in a patient with recurrent infections or with chronic pelvic pain and irritative voiding symptoms should raise the suspicion of intravesical migration of the IUD.[9] The management of a migrated IUD is controversial. However, if the IUD is found in the urinary bladder removal is mandatory.
REFERENCES [1] Mücahit Kart, Turgay Gülecen, Murat Üstüner, Seyfettin Çiftçi, Ufuk Yavuz, and Cüneyd Özkürkçügil, “Intravesical Migration of Missed Intrauterine Device Associated with Stone Formation: A Case Report and Review of the Literature,” Case Reports in Urology, vol. 2015, Article ID 581697, 4 pages, 2015. https://doi.org/10.1155/2015/581697. Avaialble at: https://www.hindawi.com/journals/criu/2015/581697/ [2] Mr Ian Beckley, Mr Roy Abrahamb, Mr Karol Rogawski Intravesical Migration of an Intrauterine Contraceptive Device. Department of Urology, Department of Obstetrics and Gynaecology2, Huddersfield Royal Infirmar. 16 Jun 2011. Available at: https://www.bjuinternational.com/case-studies/intravesical-migration-of-anintrauterine-contraceptive-device/ 3 Migraci Tosun, MD
andan Celik, MD Erhan avuz, MD Mehmet B.
etinkaya,
MD. Intravesical migration of an intrauterine device detected in a pregnant woman. Department of Obstetrics and Gynecology, Ondokuz Mayis, Samsun,
Turkey. Can Urol Assoc J. 2010 Oct; 4(5): E141–E143. PMCID: PMC2950755. doi: 10.5489/cuaj.938. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2950755/ [4] Marcus S1, Marcus D. The forgotten coil. Fertil Steril. 2011 Jan;95(1):291.e5-6. doi: 10.1016/j.fertnstert.2010.06.075. Epub 2010 Aug 2. DOI:10.1016/j.fertnstert.2010.06.075. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20674913 [5] Ozgu Aydogdu, Huseyin Pulat. Asymptomatic far-migration of an intrauterine device into the abdominal cavity: A rare entity. Can Urol Assoc J. 2012 Jun; 6(3): E134–E136. doi: 10.5489/cuaj.11100 PMCID: PMC3377742. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377742/ [6] Mohamed Ali A Ismail, Urology Department, Theodore Bilharz Research Institute, Giza, Egypt. Perforating Intravesical Intrauterine Devices: Diagnosis and Treatment. UroToday HomeVolume 1 2008Vol. 1: Issue 5. Available at: https://www.urotoday.com/volume-1-2008/vol-1-issue-5/25670-perforatingintravesical-intrauterine-devices-diagnosis-and-treatment-2218576.html [7] GHANEM, M., SULTAN, S., GHANEM, A., ZANATY, F.. Double Intravesical Migration of Intrauterine Device: Presented With Vesical Stone Formation. World Journal of Nephrology and Urology, North America, 2, dec. 2013. Volume 2, Number 2, November 2013, pages 79-81. Available at: https://www.wjnu.org/index.php/wjnu/article/view/104/91 [8] Birth Control and the IUD [INTERNET]. Available at: https://www.webmd.com/sex/birth-control/iud-intrauterine-device#1
[9] Christian Kofi Gyasi-Sarpong, Patrick Opoku Manu Maison, Emmanuel Morhe, Ken Aboah, Kwaku Addai-Arhin Appiah et al. Intravesical migration of an intrauterine device. BMC Res Notes. 2016; 9: 4. Published online 2016 Jan 2. doi: 10.1186/s13104-015-1792-6. PMCID: PMC4698325. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4698325/ [10] Zhang P, Wang T, Yang L. Extensive intravesical benign hyperplasia induced by an extravesical migrated intrauterine device: A case report. Medicine (Baltimore). 2019;98(20):e15671. doi:10.1097/MD.0000000000015671. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6531109/ [11] Dietrick DD, Issa MM, Kabalin JN, Bassett JB. Intravesical migration of intrauterine device. Department of Urology, Stanford University Hospital, California. J Urol. 1992 Jan;147(1):132-4. PMID:1729505. DOI:10.1016/s0022-5347(17)37159-8 Available at: https://www.ncbi.nlm.nih.gov/pubmed/1729505 [12] Markovitch O, Klein Z, Gidoni Y, Holzinger M, Beyth Y. Extrauterine mislocated IUD: is surgical removal mandatory? Department of Obstetrics and Gynecology, Sapir Medical Center, Kfar-Saba, affiliated with Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel. 2002 Aug;66(2):105-8. DOI: 10.1016/s0010-7824(02)00327-x. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12204783 [13] Mr Ian Beckley, Mr Roy Abrahamb, Mr Karol Rogawski. Intravesical Migration of an Intrauterine Contraceptive Device. Department of Urology1, Department of Obstetrics and Gynaecology, Huddersfield Royal Infirmary;2011. Available at: https://www.bjuinternational.com/case-studies/intravesical-migration-of-anintrauterine-contraceptive-device/
4 Bayram
uner,
zgur Arikan,
okhan Atis, utfi Canat, Turhan
askurlu.
Intravesical Migration of an Intrauterine Device. Training hospital, 34730, Istanbul, Turkey;2011. Available at: https://pdfs.semanticscholar.org/da16/f5d7877be61abe3f792e64794ed46d8b1aa3.p df [15] Tosun, Migraci & Celik, Handan & Yavuz, Erhan & Cetinkaya, Mehmet Bilge. (2010). Intravesical migration of an intrauterine device detected in a pregnant woman. Canadian Urological Association journal = Journal de l'Association des urologues du Canada. 4. E141-3. 10.5489/cuaj.938. Available at: https://www.researchgate.net/publication/47415648_Intravesical_migration_of_an_in trauterine_device_detected_in_a_pregnant_woman
Figure 1: KUB x-ray revealing the encrusted coil in the pelvis.
Figure 2: Abdominal ultrasonography showing the intrauterine contraceptive device as a bladder calculus.
Figure 3: The retrieved IUD
Table 1: Two possible mechanisms of IUD migration [1,2,7,15] A) Unforced spontaneous perforation may occur
1. Strong uterine
gradually and spontaneously with the presence of the
contractions due to
aforementioned risk factors and accompanied by an
delivery
inflamed IUD, with or without delayed symptoms.
2. Strong uterine contractions due to sexual stimulation 3. Spontaneous, irregular contraction of the bladder 4.
Bladder trauma
5.
Genital trauma
6.
Intestinal motility
7.
Peritoneal fluid movement
B) Perforation at the time of insertion(misplacement). May be asymptomatic or accompanied by acute symptoms.
8. Acute pelvic pain 9. Hemorrhage 10. Lost thread
INTRAVESICAL MIGRATION OF AN INTRAUTERINE DEVICE (IUD) Dr. Andreas P. Christodoulides , Dr. Theocharis Karaolidis MD, Phd, FEBU PII: DOI: Reference:
S0090-4295(20)30186-2 https://doi.org/10.1016/j.urology.2020.02.009 URL 21993
To appear in:
Urology
Received date: Revised date: Accepted date:
15 January 2020 27 January 2020 5 February 2020
Please cite this article as: Dr. Andreas P. Christodoulides , Dr. Theocharis Karaolidis MD, Phd, FEBU , INTRAVESICAL MIGRATION OF AN INTRAUTERINE DEVICE (IUD), Urology (2020), doi: https://doi.org/10.1016/j.urology.2020.02.009
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
TITLE PAGE/Acknowledgments INTRAVESICAL MIGRATION OF AN INTRAUTERINE DEVICE (IUD) AUTHORS First Author a) Dr. Andreas P. Christodoulides Urology Resident Nicosia General Hospital, Cyprus. Email: [email protected] Postal Address: Leoforos Larnakos 71, aprtm 102, Nicosia, Cyprus, 1046 Telephone number: 0035799337988
Corresponding Author b) Dr.Theocharis Karaolidis MD, Phd, FEBU, Urologist Nicosia General Hospital, Cyprus. Email: [email protected] Postal address: Nicosia General Hospital, Nicosia-Limassol Old Road, No.215, Strovolos, 2029, Nicosia, Cyprus. Telephone number: 0035722604398
KEYWORDS IUD, Gynecology, Urology, Coil, Case Report, Migration
ABSTRACT Intrauterine devices(IUD) are used by women worldwide as the most conventional method of reversible contraception. Migration of an IUD to pelvic or abdominal organs is considered rare. We report a case of a 67 year old female who had neglected to remove her IUD for 20 years. She visited our clinic because of recurrent UTI’s the previous year. After assessment and clinical investigation it was found that the coil had a late onset migration to the urinary bladder, with calculus formation, causing the patients’ symptoms. In our case we cystoscopically removed the encrusted coil after performing endoscopic cystolitholapaxy. The patient had an uneventful recovery and her UTI’s subsided. The objective of this article is to report the first case of intravesical IUD migration at our clinic and raise awareness of forgotten contraceptive devices and their potential complications.
INITIAL PRESENTATION A 67-year-old female was evaluated at Urology outpatient offices in August 2019. She suffered from worsening recurrent urinary tract urgency for the last year. She also had long term symptoms that included, dysuria, pelvic pressure, suprapubic and pelvic pain. The patient was sexually active without dyspareunia. She was initially diagnosed with urinary infection by her obstetrician (OB) 4 months earlier. However, after recurrence of the UTI further investigation was performed. The organisms causing her last UTIs were E.coli and enterococcus spp. The patient claimed to have suffered three urinary infections the past six months which were treated with antibiotics by her general practitioner. She mentioned that she had sporadic infections long-term but had no documents to confirm this claim. An x-ray was performed mostly in order to exclude spinal origin of the pain and this revealed a calcified opacity 3-4cm at the minor pelvis. [figure 1] A urological ultrasound confirmed the presence of stone in the urinary bladder. At the time there was no suspicion of a coil and a possible migration to an adjacent organ. She mentioned that she had had an IUD inserted around 20 years ago after her second c-section but had forgotten to remove it. Unfortunately, she didn’t recall the time of insertion. At the office, pelvic examination was normal. No visible strings coming out through the vaginal canal. Urine presented cloudy. Urine culture revealed infection by e.coli once again. Blood tests confirmed normal renal function. Her medical history included 2 caesarean sections (1982, 1986) and atrial fibrillation under Xarelto. She had no history of urolithiasis. She didn’t receive any form of imaging after the insertion of the IUD until her visit to the urology outpatient offices. Abdominopelvic
ultrasound at the office revealed a radio-opaque structure in the bladder. [figure 2] Kidneys and other internal organs were without pathological findings. The patient was then scheduled for endoscopic investigation which was performed a few days later. Rigid cystoscopy showed an encrusted, free-floating intravesical foreign body consistent with a heavily calcified IUD. Bladder wall was normal and didn’t show any signs of embedding, erosion or scarring. The patient was soon arranged for cystolitholapaxy and removal of the coil [figure 3] under anesthesia. Urethral Foley catheter was kept post-op for two days. The patient had an uneventful recovery. Her recurrent UTIs subsided and remained asymptomatic on her follow up a month later. DISCUSSION by Dr.Theocharis Karaolides MD, Phd, FEBU Several kinds of foreign bodies have been found inside urinary bladders. The literature reports an extended list including urethral dilators, wires, surgical appliances, coffee spoon handles, cables. The usual access route is via the urethra, frequently by self-introduction or in the interim of a transurethral surgical procedure. Infrequently, these objects are placed during an open or traumatic surgical process. Rarely, they can drift from a neighboring anatomical structure. [6,7] There have been several reports of intrauterine devices migrating to the urinary bladder. [1,2,3,6] An intrauterine device, also known as intrauterine contraceptive device (IUCD or ICD) or coil, is a small, often T-shaped birth control device that is inserted into a woman's uterus to prevent pregnancy. IUDs are one form of long acting
reversible birth control (LARC). [8] It has high efficacy and low complication rates and is used on over 100 million women. [1,7,9] Late complications of these devises include among others uterine perforation, malignant transition [10] and migration into neighboring structures. [11,12,13] Possible sites of IUD migration are to the bladder (intravesical), peritoneum, omentum, rectosigmoid, appendix, small bowel, colon, adnexa and iliac vein. [1,2,6] Possible complications vary from mild discomfort to more severe symptoms depending on the site of the misplacement of the IUD. Complications may include sepsis, septic abortion, ectopic pregnancy, pelvis abscess, peritonitis, appendicitis, bowel obstruction, bowel perforation, obstructive nephropathy, infertility (due to intraperitoneal adhesions), vesicouterine fistula, pulmonary embolism and death. In our case there were no symptoms related to the displacement itself and this leaves the time that the migration occurred unknown. Symptoms appeared after the coil was encrusted in the urinary bladder. This is not uncommon. Such cases can accidentally be discovered during imaging for another reason or due to the development of lower urinary symptoms.[6] The mechanism that causes uterine perforation as a result of migration or misplacement of an IUD is not completely acknowledged. Many risk factors are associated with uterine perforation. These include congenital uterine anomalies, uterine thickness, uterine position and consistency, time of insertion (first three months after delivery), past pelvic surgeries, genital infections and the applicators experience. [1,7,8,14] These factors should be regarded to with precaution and IUD insertion should be avoided when possible.
An example of unforced spontaneous perforation of the uterus and intravesical migration of an IUD is presented in our case. This is very rare with an incidence of 0.12-0.68/1000 insertions.[1] The possible mechanisms which are reported in the literature are presented on Table 1. Uterine perforation can be partial or complete, depending on if the IUD has passed completely through the uterine wall or not.[2] It is considered that calculus forms on the IUD after the device migrates to the bladder. [11,15] The time interval between insertion and symptoms varies from 6 months to 16 years, unless the patient presents with acute symptoms. In our case the patient presented with dysuria and recurrent UTIs after 20 years of insertion. It is not possible to know when the IUD migrated into the urinary bladder. However, this must be related to the appearance of her urinary tract infections almost one year before she was referred to us. It is well known that women with recurrent UTIs (≥2 infections in six months or ≥3 infections in one year) should undergo further investigation. One of the rare reasons of recurrent UTIs is foreign bodies in the urinary bladder. A combination of lower urinary tract symptoms and a history of an unretrieved IUD should set the suspicion of potential perforation of the uterus and intravesical migration/mislocation. When IUD strings are not inspected in the vagina during examination and are not detected in the endometrial cavity using ultrasonography, a physician must contemplate IUD displacement.
In addition, bladder stones are an unusual finding in female patients, which should raise skepticism of the presence of a foreign body in the bladder. All extrauterine copper-laden devices should be removed, as copper IUDs result in inflammatory reactions and adhesions. The World Health Organization (WHO) and the International Medical Advisory Panel Meetings of the International Planned Parenthood Federation recommend that an IUD displaced from the uterine cavity should be removed as soon as possible after diagnosis, regardless of its type and location. Whilst surgical procedures to remove a misplaced IUD must be performed on symptomatic patients, asymptomatic patients, under certain circumstances, may favor from conservative management. [12] Treatment options for intravesical IUDs differ. IUDs that are situated fully in the bladder, with or without small calculi, can be retrieved by cystoscopic or suprapubic cystoscopic extraction. Laparoscopic surgery or open surgery can be used for the removal of coils with big stone development or with fractional invasion of the bladder wall [13]. Consequently, treatment options for displaced IUDs must be chosen carefully because of the increase in morbidity by open surgery and because of patient preferences for least invasive procedures. Pre-operative assessment may include axial imaging CT scan or endoscopic evaluation with cystoscopy. In the present case we removed the IUD cystoscopically after manual stone lithotripsy with no further complications.
CONCLUSIONS Recurrent urinary tract infections should trigger further investigation. Gynecological history should be included in this procedure. A history of an unretrieved IUD in a patient with recurrent infections or with chronic pelvic pain and irritative voiding symptoms should raise the suspicion of intravesical migration of the IUD.[9] The management of a migrated IUD is controversial. However, if the IUD is found in the urinary bladder removal is mandatory.
REFERENCES [1] Mücahit Kart, Turgay Gülecen, Murat Üstüner, Seyfettin Çiftçi, Ufuk Yavuz, and Cüneyd Özkürkçügil, “Intravesical Migration of Missed Intrauterine Device Associated with Stone Formation: A Case Report and Review of the Literature,” Case Reports in Urology, vol. 2015, Article ID 581697, 4 pages, 2015. https://doi.org/10.1155/2015/581697. Avaialble at: https://www.hindawi.com/journals/criu/2015/581697/ [2] Mr Ian Beckley, Mr Roy Abrahamb, Mr Karol Rogawski Intravesical Migration of an Intrauterine Contraceptive Device. Department of Urology, Department of Obstetrics and Gynaecology2, Huddersfield Royal Infirmar. 16 Jun 2011. Available at: https://www.bjuinternational.com/case-studies/intravesical-migration-of-anintrauterine-contraceptive-device/ 3 Migraci Tosun, MD
andan Celik, MD Erhan avuz, MD Mehmet B.
etinkaya,
MD. Intravesical migration of an intrauterine device detected in a pregnant woman. Department of Obstetrics and Gynecology, Ondokuz Mayis, Samsun,
Turkey. Can Urol Assoc J. 2010 Oct; 4(5): E141–E143. PMCID: PMC2950755. doi: 10.5489/cuaj.938. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2950755/ [4] Marcus S1, Marcus D. The forgotten coil. Fertil Steril. 2011 Jan;95(1):291.e5-6. doi: 10.1016/j.fertnstert.2010.06.075. Epub 2010 Aug 2. DOI:10.1016/j.fertnstert.2010.06.075. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20674913 [5] Ozgu Aydogdu, Huseyin Pulat. Asymptomatic far-migration of an intrauterine device into the abdominal cavity: A rare entity. Can Urol Assoc J. 2012 Jun; 6(3): E134–E136. doi: 10.5489/cuaj.11100 PMCID: PMC3377742. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377742/ [6] Mohamed Ali A Ismail, Urology Department, Theodore Bilharz Research Institute, Giza, Egypt. Perforating Intravesical Intrauterine Devices: Diagnosis and Treatment. UroToday HomeVolume 1 2008Vol. 1: Issue 5. Available at: https://www.urotoday.com/volume-1-2008/vol-1-issue-5/25670-perforatingintravesical-intrauterine-devices-diagnosis-and-treatment-2218576.html [7] GHANEM, M., SULTAN, S., GHANEM, A., ZANATY, F.. Double Intravesical Migration of Intrauterine Device: Presented With Vesical Stone Formation. World Journal of Nephrology and Urology, North America, 2, dec. 2013. Volume 2, Number 2, November 2013, pages 79-81. Available at: https://www.wjnu.org/index.php/wjnu/article/view/104/91 [8] Birth Control and the IUD [INTERNET]. Available at: https://www.webmd.com/sex/birth-control/iud-intrauterine-device#1
[9] Christian Kofi Gyasi-Sarpong, Patrick Opoku Manu Maison, Emmanuel Morhe, Ken Aboah, Kwaku Addai-Arhin Appiah et al. Intravesical migration of an intrauterine device. BMC Res Notes. 2016; 9: 4. Published online 2016 Jan 2. doi: 10.1186/s13104-015-1792-6. PMCID: PMC4698325. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4698325/ [10] Zhang P, Wang T, Yang L. Extensive intravesical benign hyperplasia induced by an extravesical migrated intrauterine device: A case report. Medicine (Baltimore). 2019;98(20):e15671. doi:10.1097/MD.0000000000015671. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6531109/ [11] Dietrick DD, Issa MM, Kabalin JN, Bassett JB. Intravesical migration of intrauterine device. Department of Urology, Stanford University Hospital, California. J Urol. 1992 Jan;147(1):132-4. PMID:1729505. DOI:10.1016/s0022-5347(17)37159-8 Available at: https://www.ncbi.nlm.nih.gov/pubmed/1729505 [12] Markovitch O, Klein Z, Gidoni Y, Holzinger M, Beyth Y. Extrauterine mislocated IUD: is surgical removal mandatory? Department of Obstetrics and Gynecology, Sapir Medical Center, Kfar-Saba, affiliated with Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel. 2002 Aug;66(2):105-8. DOI: 10.1016/s0010-7824(02)00327-x. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12204783 [13] Mr Ian Beckley, Mr Roy Abrahamb, Mr Karol Rogawski. Intravesical Migration of an Intrauterine Contraceptive Device. Department of Urology1, Department of Obstetrics and Gynaecology, Huddersfield Royal Infirmary;2011. Available at: https://www.bjuinternational.com/case-studies/intravesical-migration-of-anintrauterine-contraceptive-device/
4 Bayram
uner,
zgur Arikan,
okhan Atis, utfi Canat, Turhan
askurlu.
Intravesical Migration of an Intrauterine Device. Training hospital, 34730, Istanbul, Turkey;2011. Available at: https://pdfs.semanticscholar.org/da16/f5d7877be61abe3f792e64794ed46d8b1aa3.p df [15] Tosun, Migraci & Celik, Handan & Yavuz, Erhan & Cetinkaya, Mehmet Bilge. (2010). Intravesical migration of an intrauterine device detected in a pregnant woman. Canadian Urological Association journal = Journal de l'Association des urologues du Canada. 4. E141-3. 10.5489/cuaj.938. Available at: https://www.researchgate.net/publication/47415648_Intravesical_migration_of_an_in trauterine_device_detected_in_a_pregnant_woman
Figure 1: KUB x-ray revealing the encrusted coil in the pelvis.
Figure 2: Abdominal ultrasonography showing the intrauterine contraceptive device as a bladder calculus.
Figure 3: The retrieved IUD
Table 1: Two possible mechanisms of IUD migration [1,2,7,15] A) Unforced spontaneous perforation may occur
1. Strong uterine
gradually and spontaneously with the presence of the
contractions due to
aforementioned risk factors and accompanied by an
delivery
inflamed IUD, with or without delayed symptoms.
2. Strong uterine contractions due to sexual stimulation 3. Spontaneous, irregular contraction of the bladder 4.
Bladder trauma
5.
Genital trauma
6.
Intestinal motility
7.
Peritoneal fluid movement
B) Perforation at the time of insertion(misplacement). May be asymptomatic or accompanied by acute symptoms.
8. Acute pelvic pain 9. Hemorrhage 10. Lost thread