Ectopic intrauterine device in the bladder causing cystolithiasis:A case report

lNTRODUCTlON

According to the 1998 annual report of the World Health Organization, intrauterine devices (IUDs) are a cost-effective, reversible contraceptive method. They are commonly used worldwide and are the main contraceptive method among Chinese women[1]. According to statistics, the incidence of IUD displacement is approximately 0.1%-0.3%[2]. The spontaneous displacement of an IUD into the periuterine area may cause serious complications, such as vesicouterine fistulas, intestinal perforation, hydronephrosis, and even renal failure[3-7]. Intravesical translocation of an IUD is rare and may present as suprapubic pain or discomfort, dysuria, recurrent urinary tract infections, or stone formation. Removal through endoscopy or open surgery is currently recommended as the best treatment option. Herein, we report a case of a patient who presented with recurrent urinary tract infections and was incidentally found to have an IUD partially positioned in the bladder through computed tomography (CT).

CASE PRESENTATlON

Chief complaints

The primary complaints included urinary frequency, urgency, and pain over a period of three months.

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History of present illness

A 44-year-old woman was hospitalized in our department for a 3-mo history of urinary frequency, urgency, and pain. She denied fever, lumbago, back pain, and hematuria.

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History of past illness

The patient had no contributory medical history, except for an IUD implantation seven years prior.

Personal and family history

The patient had no pertinent family history.

Physical examination

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Laboratory examinations

A routine urinary examination was performed when the patient first developed symptoms. The examination results were as follows:844 red blood cells/uL, 1063 white blood cells/uL, and 1873 bacteria/uL. She was treated with antibiotics; however, after 3 mo, another routine urine analysis demonstrated 131 red blood cells/uL, 330 white blood cells/uL, and 432 bacteria/uL. After she was hospitalized, her urine test showed 3 red blood cells/uL, 25 white blood cells/uL, and 5 bacteria/uL. A urine culture demonstrated colonization with.

Imaging examinations

FlNAL DlAGNOSlS

Considering the patient’s history and laboratory and imaging findings, the patient was diagnosed with an ectopic IUD.

TREATMENT

We administered cefoxitin (2 g intravenously every 8 h) based on the patient’s urine culture results and drug sensitivity test. CT, cystoscopy, and hysteroscopy demonstrated that majority of the IUD was located in the uterine cavity; however, the portion of the IUD in the bladder was complicated due to multiple stones. Thus, we decided to use a holmium laser (Lumenis, Holmium 1.0 J × 20 Hz) to break the stones during cystoscopy and removed the ectopic IUD from the uterine cavity with the hysteroscope (Figure 3). We reassessed the bladder and uterus at the end of the procedure and confirmed that there was no obvious bleeding or fistula.

OUTCOME AND FOLLOW-UP

The patient had no obvious hematuria or vaginal bleeding after surgery. The urinary catheter was removed after one week, and the patient's lower urinary tract symptoms showed complete resolution. A routine urine examination was performed after three months and demonstrated no obvious abnormalities.

DlSCUSSlON

Clinically, bladder injury caused by an IUD may present with dysuria, hematuria, and lower abdominal pain[15]. Most patients with IUDs have a medical history of urinary tract infections or hematuria for which they have received treatment. As reported, urinary tract infections are the most common manifestation of bladder perforation with an IUD. For patients with a history of IUD implantation, recurrent urinary tract infections or intermittent hematuria should increase the suspicion for an ectopic IUD. The diagnosis of an ectopic IUD in the bladder mainly depends on imaging examinations. B-mode ultrasonography can be utilized for screening, but a definitive diagnosis requires a CT, cystoscopy, or hysteroscopy. There is currently no standard surgical treatment for this condition. Displaced IUDs can be optimally managed through hysteroscopy, cystoscopy, laparoscopy, or a combination of these procedures, with the location of the ectopic IUD determining the treatment option[13,16-18]. A recent study proposed an innovative combination of carbon dioxide cystoscopy and laparoscopy for IUD removal with a partial cystectomy[17].

As reported in the literature, IUDs are most commonly displaced into the omentum (26.7%), uterorectal depression (21.5%), colorectal cavity (10.4%), myometrium (7.4%), broad ligament (6.7%), or abdominal cavity (5.2%)[8]. The translocation of an IUD through uterine perforation and into the bladder wall is rare, with an incidence of approximately 0.05-1.3/1000[9]. Κart[10] reported 200 cases of ectopic IUDs, 90 of which were located in the bladder. Goldbach[11] reported a higher incidence of ectopic Multiload Cu375 (MCu) II functional IUDs compared to other IUDs. Sun[12] suggested that the MCu II IUD was similar to the V-type IUD as both have sharp side walls that easily distort when the device is handled or inserted incorrectly. The mechanism of IUD displacement is unclear but may be related to breastfeeding, the proximity of IUD implantation to recent delivery (up to 36 wk), surgeon’s experience and skill in implanting IUDs, or a history of cesarean section[13]. Esposito[14] proposed two mechanisms for IUD displacement, which included immediate perforation during insertion and a secondary process of gradual erosion.

CONCLUSlON

In conclusion, we reported a case of an ectopic IUD in the bladder that was documented seven years after IUD insertion. Among women of childbearing age with a history of IUD placement, repeated lower urinary tract symptoms, and hematuria, an ectopic IUD in the bladder should be considered. Ultrasound or CT can be used to confirm the diagnosis. Cystoscopy and hysteroscopy should be performed to guide surgical treatment. Removal of the ectopic IUD through the urethra or vagina is the least traumatic course.

No obvious signs were found on physical examination. The patient did not demonstrate any pain on percussion of the bilateral renal areas or obvious tenderness along the path of the ureters. The patient exhibited normal external genitalia.

The patient had recurring symptoms of urinary tract infection. Combined with her history of IUD implantation, we considered IUD displacement. CT revealed an abnormally positioned IUD, which had penetrated the uterine wall and was protruding forward into the bladder (Figure 1). Cystoscopic and hysteroscopic exploration was subsequently scheduled. Cystoscopy was performed with a 22-Fr cystoscope with a 70° lens. Cystoscopy demonstrated an IUD, which had penetrated the left posterior bladder wall. Approximately 1 cm of the IUD was located in the bladder cavity, and a large number of stones were visible on its surface (Figure 2A). Subsequently, hysteroscopy demonstrated a V-shaped IUD in the middle section of the cervical canal. One of the arms of the IUD was notably incarcerated in the muscular layer of the canal (Figure 2B).

We acknowledge the patient for her cooperation and trust in our treatment.

A review of the current literature indicated that patients with bladder stones caused by ectopic IUDs should undergo preoperative cystoscopy, hysteroscopy (or transvaginal ultrasound), and CT imaging to determine the location of the IUD and facilitate surgical planning[19]. In the present case, the V-type IUD was only displaced approximately 1 cm into the bladder. Cystolithiasis occurred in this short segment, but the majority of the IUD was still located in the uterine cavity. We elected to use a holmium laser to break the calculi on the portion of the IUD in the bladder, and then removed the IUD through the vagina.

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Gou X designed this study; Yu HT, Chen Y, Xie YP, and Gan TB collected the information; Yu HT wrote the paper; and all authors issued final version of the paper.

Informed written consent was obtained from the patient for publication of this report and any accompanying images.

China

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See:https://creativecommons.org/Licenses/by-nc/4.0/

The authors declare that they have no conflict of interest.

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Hai-Tao Yu 0000-0002-9745-8418; Yong Chen 0000-0002-2659-8499; Yong-Peng Xie 0000-0002-7165-9991; Ting-Bin Gan 0000-0002-2542-1720; Xin Gou 0000-0003-3062-209X.

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