Intravesical Migration of an Intrauterine Device Managed with Holmium Laser Lithotripsy : Current Urology

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Case Report

Intravesical Migration of an Intrauterine Device Managed with Holmium Laser Lithotripsy

Yee, David S.; Perer, Elise; Hovey, Regina M.

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Current Urology 2(2):p 100-102, November 2008. | DOI: 10.1159/000115416
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Abstract

Introduction

The intrauterine contraceptive device (IUD) has been an effective method of contraception for over 30 years, however, is not without complication. IUD migration with resultant calculus formation is a rare complication with fewer than 20 cases reported in the literature [1]. We report our experience with the holmium laser in the endoscopic treatment of an intravesically migrated IUD and its associated calculus.

Case Report

A 28-year-old female, gravida 2, para 2, presented with 5-month history of progressively worse irritative voiding symptoms and recurrent urinary tract infections treated empirically with antibiotics. Her complaints included intermittent lower abdominal pain, urinary frequency, urgency, and dysuria. She denied any incontinence. Five years ago, she had an IUD placed without complication and its position confirmed on a follow-up examination.

Physical examination revealed some mild suprapubic tenderness and a string exiting from her urethra with stones attached (fig. 1). A plain abdominal radiograph revealed a foreign body in the pelvis (fig. 2). Computed tomography scan showed a foreign body entirely within the bladder and urethra suspicious for an IUD.

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Fig. 1.:
Pelvic examination showing a string exiting from her urethra with attached stones.
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Fig. 2.:
A plain abdominal radiograph demonstrates a stone-encrusted IUD in the pelvis.

A pelvic exam under anesthesia did not reveal any vesicovaginal or vesicouterine fistula. Cystoscopy confirmed a heavily stone-encrusted IUD present within the bladder. No vesicovaginal or vesicouterine fistula was noted. A 1,000 micron holmium laser fiber on a setting of 800 millijoules and 8 Hz was used to fragment the stone-encrusted IUD and amputate one arm to facilitate its removal endoscopically (fig. 3). The patient tolerated the procedure well and was discharged home on the postoperative day one.

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Fig. 3.:
Migrated IUD (Copper-T) with amputated arm and stone formation.

Discussion

Although the IUD has been a reliable contraceptive method for many years, its use has been associated with some complications. Major complications include uterine perforation and migration into adjacent organs. The incidence of uterine perforation ranges from 1 to 3 per 1,000 insertions [2]. Most IUD migration occurs to the adjacent organs, however, some have been found in the peritoneum, omentum, appendix, and rectum [3-6].

Although the exact mechanism of IUD intravesical migration is unknown, uterine perforation and migration is likely closely related to the timing of insertion, IUD type, insertion technique, and anatomy of the cervix and uterus [2]. Risk of perforation increases following Cesarean section and in the immediate postpartum or postabortal period when there may be thinning of the uterine wall. Gradual IUD migration through the uterine wall may occur by pressure necrosis and uterine contractions [7]. The risk of perforation will also vary with the physician’s insertion technique and experience. In addition, the Copper-T has been associated with the majority of IUD migration cases as in our patient [1, 7-9].

Intravesical migration of an IUD has been reported in nearly 80 cases in the literature, however, less than a third of these cases have resulted in bladder calculus formation [1, 7-10]. The majority of patient with bladder calculi secondary to migrated IUDs present with irritative lower urinary tract symptoms, hematuria, suprapubic discomfort, and recurrent urinary tract infections. IUD intravesical migration should be considered in the differential diagnosis in any women previously fitted with an IUD who experiences these clinical symptoms [10].

Diagnostic evaluation should include a plain abdominal radiograph, which may diagnose bladder perforation by demonstrating an IUD with an attached bladder calculus [7, 8]. Most IUDs are strongly radiopaque, except for the less opaque Dalkon shield [9]. Ultrasonography and computed tomography scan may also help determine the position of the foreign body [1]. Cystoscopy will confirm the presence of an IUD in the bladder and help plan the optimal approach for its removal [7, 8].

An intravesical IUD must be removed because of its potential complications, including calculus formation and recurrent urinary tract infections. Treatment options for a migrated IUD with secondary calculus formation include a suprapubic cystostomy or endoscopic techniques. The use of a holmium laser is a minimally invasive technique to facilitate endoscopic removal of an IUD and its accompanying stone burden. This is the first documented case that reports the use of the holmium laser in endoscopically removing a stone-encrusted IUD in the bladder.

References

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Keywords:

Bladder calculi; Foreign body migration; Lithotripsy; Intrauterine device

Copyright © 2008 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.