Forgotten Intrauterine Contraceptive Device Presenting as Vesicouterine Fistula – Migration or Misadventure

ABSTRACT

Intrauterine contraceptive device (IUD) is one of the most commonly used long-term contraceptive methods worldwide. Migration of IUD is one of the rare complications of IUD insertion. Migrated IUD with calculus formation is a rarer long-term complication of IUD. A 55-year-old postmenopausal woman attended the outpatient clinic with complaints of continuous dribbling of urine. On examination, there was pooling of urine in the posterior fornix of the vagina, and the calcified vertical stem of the IUD was visualized through the cervical os. On evaluation, a giant calculus was noted within the bladder arising from the perforated IUD arm with vesicouterine fistula. Vesical lithotripsy followed by fistulous tract excision with repair of bladder wall was done.

INTRODUCTION

Intrauterine contraceptive devices are commonly used methods of contraception globally. Copper T intrauterine contraceptive device (IUD) is a nonhormonal method with least side effects, and due to its low-cost, long-acting, and immediate reversible nature, it is widely used in all parts of the world. Uterine perforation is one of the most dangerous complications, and it is extremely uncommon for the IUD to migrate into the bladder following uterine perforation.[1] A migrated IUD inside the bladder serves as a nidus for the calculus formation.[2,3] Here, we report a rare case of migration of neglected copper T IUD into the bladder and subsequent giant calculus formation with vesicouterine fistula which is extremely rare.

CASE REPORT

A 55-year-old postmenopausal woman attended the gynecology outpatient clinic with complaints of continuous dribbling of urine and dysuria for the past 3 months. She had a normal vaginal delivery 22 years ago. She denies a history of usage of any contraceptive method. There was no history of recurrent urinary tract infections and abnormal uterine bleeding. She attained menopause at the age of 45 years and had no history of postmenopausal bleeding. Her general and systemic examinations were normal. During the gynecological examination, pooling of urine in the posterior fornix of the vagina was present, and the calcified vertical stem of the copper T IUD was visualized through the cervical os [Figure 1a]. The uterus was atrophic, and there was no uterine and forniceal tenderness.

Figure 1.

(a) Speculum examination showing calcification of IUCD through the cervix, (b) computed tomography of kidney, ureter, and bladder (CT KUB) showing IUD in the uterus and its limb in the urinary bladder with calculus

The computed tomography of the kidney, ureters, and bladder (CT KUB) showed a giant calculus measuring 4 cm × 4 cm noted within the bladder originating from the perforated IUD arm. The horizontal arm of the IUD has perforated the uterine myometrium and serosa of the lower uterine segment and part of it has migrated into the bladder wall with the formation of a vesicouterine fistula [Figure 1b]. X-ray KUB revealed a giant calculus with a perforated copper IUD.

The patient was then planned for cystoscopy and vesical lithotripsy with copper T removal. During cystoscopy, IUD was found incorporated in a 4 cm × 4 cm calculus [Figure 2a]. The stem of the copper IUD was found migrated through the posterior wall of the urinary bladder, and a small vesicouterine fistula [Figure 2b] was noted in the posterior wall of the bladder through which IUD was protruding after vesiculo-lithotripsy. The copper IUD was then removed. The patient was then kept under observation with continuous bladder drainage for the healing and closure of the fistulous tract for 6 weeks.

Figure 2.

(a) Cystoscopy showing IUD incorporated in a 4 cm × 4 cm calculus, (b) Postvesiculo-lithotripsy – Perforated IUCD in the posterior wall of the urinary bladder

The fistulous tract, though small in size, has not healed and so we proceeded to a more definitive surgery. Prophylactic stenting of ureters were done as an initial measure and then proceeded to laparotomy. The perforation was noted in the anterior wall at the level of the isthmus [Figure 3a]. The procedure was then proceeded to total abdominal hysterectomy and fistula repair. Suprapubic catheter and urethral catheter were placed. Ureteric stents were removed on postoperative day 7, urethral catheter was removed on postoperative day 14, and suprapubic catheter was removed on postoperative day 16. The patient voided without difficulty following catheter removal with no continuous dribbling of urine. Postoperative CT cystogram was normal with complete resolution of fistula [Figure 3b].

Figure 3.

(a) Vesicouterine fistula at the level of the isthmus, (b) Postoperative computed tomography cystogram showing complete resolution of fistula

DISCUSSION

Migration of IUD is a rare complication, and the estimated incidence of IUD migration into the adjacent structures is 1 in 1000 insertions.[4] The migration usually occurs following partial or complete perforation during insertion. They usually present with urinary tract complaints, menstrual complaints, and discharge per vaginum when there is bladder migration.[5,6] The migration may be further aided by the local inflammation caused by copper in the IUD.[7]

On the contrary, one may diagnose migrated IUD during the evaluation of some other symptoms[8] or symptoms of vesicouterine fistula may be the presentation[9] just like our case. The presence of a foreign body inside the bladder is a very well-known risk factor for bladder calculi formation. Apart from aiding the migration of IUD inside the bladder, the copper in the IUD acts as nidus and calcium accumulates to form bladder calculi. Foreign bodies in the bladder can cause intravesical calculus formation.[10,11]

Vesicouterine fistula is a rare urogenital fistula, caused by prolonged and obstructed labor in developing countries and cesarean section in developed countries. Other causes include manual removal of the placenta, abnormal placentation, migrated IUD, inflammatory bowel disease, pelvic irradiation, and forceps delivery.[12,13,14]

Vesicouterine fistula is classified into three types based on the routes of menstrual flow. Type 1 has a triad of amenorrhea, menouria, and complete urinary continence. It is also called Youssef’s syndrome. Type 2 is characterized by dual menstrual blood flow through the bladder and vagina. Type 3 has no menstrual abnormality and no menouria. Our patient fits into Type 3 category.[15]

There are different treatment options available following the diagnosis of migrated IUD with bladder stone formation. If the migrated IUD is completely inside the bladder with no signs of fistula, it can be removed simply by cystoscopy.[2] If there is a bladder stone along with an IUD that lies completely inside the bladder, lithotripsy, and IUD removal can be done cystoscopically, provided that there is no fistula.[16] If the stone size is large or when there is partial penetration of the bladder wall or there is an associated fistula, open surgery is the method of choice[17,18] just like our case.

In our case, we decided to go for lithotripsy with copper T IUD removal cystoscopically followed by fistula repair. Initially, lithotripsy was done and IUD was removed completely through cystoscopy. This reduced the size of cystotomy incision made for fistula repair since it was a giant bladder calculus measuring 4 cm × 4 cm. The decision to proceed for hysterectomy was made as the fistulous connection was present at the level of the isthmus of the uterus, and there is a high chance of recurrence due to its close proximity with the bladder.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.