A Mislocated Intrauterine Device Migrating to the Urinary Bladder: An Uncommon Complication Leading to Stone Formation

Intrauterine devices are a popular form of reversible contraception among women. Its administration can lead to some uncommon but serious complications such as perforation leading to its migration into adjacent organs. Like any foreign body, the presence of an IUD in the bladder can result in stone formation due to its lithogenic potential. We report a case of an IUD migrating from its normal position in the uterine cavity into the urinary bladder causing chronic low urinary tract symptoms in a 43-year-old female patient. The device was securely removed without complications using grasping forceps under cystoscopy, and no parietal defect was detected. A mislocated IUD is a rare complication that should be considered in female patients presenting with chronic urinary symptoms.


Introduction
Intrauterine devices (IUD) are a frequently used reversible form of contraception.
As any medical device, its administration can lead to complications such as perforation and extrauterine migration to adjacent organs.
The most common sites for IUD migration are the omentum, rectum, sigmoid colon, peritoneum, and bladder [1].
Here, we report a case of an IUD migrating from the uterus cavity into the urinary bladder.

Case Presentation
A 43-year-old female was referred to our outpatient department for a one-year history of chronic pelvic pain with lower urinary tract symptoms such as dysuria, urgency, and pollakiuria.
Her medical history was unremarkable other than the insertion of a Copper-T IUD four years ago by her gynaecologist and with no regular follow-up afterwards.
Physical pelvic examination was normal. Urinalysis was indicative of leucocyturia, but urine culture was negative.
An abdominal ultrasonography revealed an echogenic intravesical lesion suggestive of urinary bladder calculus ( Figure 1).
Plain abdominal radiography did not show any stone but demonstrated the IUD in the lower left quadrant of the abdomen (Figure 2).
A cystoscopy was done after written informed consent of the patient. It revealed a calcified T-shaped foreign object identified as the IUD, embedded into the muscular wall of the bladder.
No stones were found. The IUD was extracted easily with gentle traction using endoscopic forceps.
After the removal of the foreign object, we did not find any fistula tract between the posterior wall of the bladder and the uterus.
One month following the procedure, the patient was reassessed and reported a significant improvement in lower urinary symptoms including no evidence of infections in the urine culture or persistence of fistula at the flexible cystoscopy.

Discussion
Intrauterine device is a regular form of mechanical contraception widely used. More than 150 million women use IUDs, mainly in emerging countries [2].
Its administration can be accompanied by several complications.
Perforation is one the most serious but rare complication secondary to the insertion of IUD, eventually leading to its migration from its normal position in the fundus either into the abdominal cavity or into other organs adjacent to the uterus.
The incidence of perforation is estimated as being between 1.9 and 3.6 per 1000 insertions [3].
The true incidence of perforation is most likely higher because of the frequently asymptomatic nature of the perfo-ration, with over 30% of perforations recognized only when pregnancy [4].
The urinary bladder is one of the organs where the mislocated IUD can be embedded. Table 1 shows five similar cases with different therapeutic approaches reported in literature.
Bladder stones (BS) are uncommon in women. Approximately, 5% of bladder stones occur in female patients [5].
Therefore, foreign bodies should be considered when assessing the presence of BS.
These foreign bodies such as IUD in this case, with their lithogenic potential, act as a nidus for stone formation in the urinary bladder [6].
Although perforation of the uterus by IUD is often a silent phenomenon, erosion of the bladder wall is usually symptomatic [7].
In this case, the patient presented with irritative low urinary tract symptoms, such as frequency and urgency, frequently associated with haematuria.
Recurrent urinary tract infections, chronic pelvic pain syndrome, and sexual complaints such as dyspareunia can be part of the clinical manifestations.
Typically, at pelvic examination, the retrieval string of the IUD should protrude approximately 2-3 cm through the external cervical os.
A missing string is a common and strong indication of displacement, uterine perforation, or expulsion.
Various imaging modalities can be used in the evaluation of IUDs and in establishing the etiological diagnosis of low urinary tract symptoms in female patients.
Abdominal ultrasonography (US) can easily help determine whether the IUD is correctly positioned.
IUD displacement and myometrial perforation can be fully investigated by performing US alone [8].
However, abdominal radiography can be helpful in demonstrating an extrauterine IUD.
In some cases, the IUD can be misdiagnosed for a bladder stone due to the calcium tone opacity acquired when intravesical.
Thus, diagnostic cystoscopy allows a direct visualisation of the bladder, allowing to identify the foreign body, its extraction using a mechanical forceps if possible, and the search for any vesicouterine fistula.
However, the management of migrated IUDs is controversial.
According to the World Health Organization (WHO) recommendation, any translocated IUD following uterine perforation within the abdomen should be removed whether symptomatic or asymptomatic irrespective of location [9].
An IUD that migrated to the bladder eventually leads to stone formation, making its removal necessary.
Three approaches to remove the device include the use of open cystolithotomy, transurethral grasping forceps, or minimally invasive laparoscopy [10].
Open and laparoscopic surgery should be considered for the removal of IUD with partial penetration due to the possibility of a vesicouterine fistula that needs repair [7].
In case of endoscopic approach, both the cystoscope and the transurethral nephroscope can be used.   Case Reports in Urology

Case Reports in Urology
Ballistic or laser lithotripsy should be used for the initial fragmentation of the calculi that formed around the IUD to facilitate its extraction.
In this case, cystoscopy was sufficient for the management of this mislocated IUD.
Although delicate surgical procedures are available nowadays, traditional noninvasive options such as herbal formulas have been reported for patients living in developing areas with known or unidentified mechanisms of actions, but an evidence based practice should be kept in mind [11].

Conclusion
IUD migrating to the urinary bladder is an uncommon complication that should be considered in female patients complaining of chronic low urinary tract symptoms.
Endoscopic approach of a mislocated IUD is considered a safe and effective minimally invasive approach.