The rolling stone: migration of an intrauterine device leading to bladder stone formation nine years after insertion: a case report

Abstract

Background

Intrauterine devices are safe, affordable, convenient, and the most common form of contraception used by females of childbearing age in Palestine. A rare complication of intrauterine devices is migration to nearby structures, rarely the urinary bladder, leading to bladder stone formation.

Case presentation

A 34-year-old female patient presented due to repeated urinary tract infections and flank pain associated with lower urinary tract symptoms, including dysuria, frequency, and gross hematuria. Subsequent laboratory tests revealed a past medical history of iron-deficiency anemia. Urinalysis revealed hematuria and pyuria, and the urine culture confirmed colonization of Escherichia coli. Computed tomography revealed an irregularly shaped 5.5 cm hyperdense calculus in the urinary bladder. Open cystolithotomy was done to extract the calculus, which was later incidentally revealed to be encrusting a migrated intrauterine device.

Conclusions

This case highlights the rare potential for intrauterine devices to migrate to the urinary bladder, leading to calculus formation, which, in this case, was discovered in this patient nine years post-insertion. The intrauterine device perforation into the urinary bladder was due to delayed inflammatory migration. This case underscores the critical need for both patient and physician education in low-resource settings on the warning signs of intrauterine device migration, including new-onset irritative lower urinary tract symptoms, hematuria, and missing intrauterine device threads, ensuring routine scheduled follow-ups, patient self-checks, and timely imaging can aid in early detection and prevent complications associated with intrauterine device migration.

Background

Urinary bladder calculi or cystoliths are an uncommon clinical condition, accounting for only 5% of all urinary tract calculi, and are more frequently seen in men over sixty [1]. The symptoms associated with bladder calculi are usually vague, and in many cases, patients may be asymptomatic. A rare iatrogenic cause of cystoliths is migrated intrauterine devices (IUDs) into the urinary bladder. IUDs are one of the most utilized long-term contraceptive methods. It is used by approximately 161 million women of reproductive age worldwide as of 2022 [2]. In Palestine, it is the most common form of contraception [3].

Reports describing IUD migration leading to cystolith development have been reported in the past [4]. Our case presents distinctive features, including a considerably larger calculus (5.5 cm) and a delayed diagnosis nine years post-insertion. Additionally, this report highlights the importance of patient and physician education regarding the warning signs of IUD migration and how socioeconomic status barriers lead to a delay in medical evaluation and treatment.

We present a case of a 34-year-old female with complete migration of a copper IUD to the urinary bladder, which acted as a nidus for calculus formation, leading to the discovery of a large cystolith. This case has been reported in accordance with the Surgical Case Report (SCARE) 2020 criteria [5].

Case presentation

A 34-year-old female patient, gravida 4, para 3, abortus 1 (G4P3A1), presented to our urology clinic in Al-Hussein Governmental Hospital in Bethlehem, Palestine, in November 2023, complaining of “low back pain and burning sensation while urinating with occasional blood” for five years. The patient had a history of using a Copper T IUD for contraception, which was inserted by her gynecologist in 2014 without regular follow-up. One year after the IUD insertion, the patient had an unexpected pregnancy which resulted in a normal vaginal delivery, an event her gynecologist attributed to spontaneous IUD expulsion. A second IUD was inserted one month postpartum. In 2019, the patient began experiencing gross hematuria along with irritative Lower Urinary Tract Symptoms (LUTS), including dysuria, nocturia, and urinary frequency associated with generalized weakness. Additionally, the patient described bilateral low back pain, which radiates to the suprapubic region and has been ongoing since then, associated with heavy menstruation lasting ten days on average and sometimes occurring twice per month. Laboratory testing prior to her visit revealed a history of iron deficiency anemia. The patient describes the pain as moderate in severity, colicky in nature, and not relieved or alleviated by any factor. In November 2023, the patient presented to the urology clinic for further follow-up as she had been experiencing LUTS since 2019 and was hospitalized at another hospital in 2019 for a severe Urinary Tract Infection (UTI), which was treated successfully. However, the LUTS continued after treatment. Currently, the patient’s pain is also associated with new-onset constitutional symptoms such as sudden weight loss, anorexia, nausea, undocumented fevers, chills, and fatigue. The patient had no significant surgical history, drug, or relevant family history. Physical examination revealed a distended lower abdomen with tenderness to palpation. Urinalysis showed a turbid urine sample with + 2 hematuria, 8–10 Red Blood Cells (RBCs)/hpf, and many White Blood Cells (WBCs)/hpf. However, no casts, crystals, or sediment were found. Further tests included a urine culture, which identified the presence of E. coli bacteria, with a concentration of 50,000 CFU/ml via a midstream catch urine sample. Routine blood tests were normal. Past medical history was significant for a hospitalization at another facility. The patient presented us with a discharge report from that facility which described her medical history and the need for a blood transfusion in July 2023, when she was admitted for an episode of syncope where lab results showed C-Reactive Protein (CRP) 129.9 mg/L, Lymphocytes 500 cell/mL, mean corpuscular hemoglobin (MCH) 18 pg/cell, mean corpuscular volume (MCV) 58.1 fL, Hematocrit 22.6%, RBC count 3.89 million/µL and Hemoglobin 7 g/dL. The patient was discharged when stabilized, and her anemia was corrected. The patient was referred to a hematologist to investigate the cause of her anemia, but she was lost to follow-up. A plain Kidney, Ureter, and Bladder (KUB) X-ray revealed an IUD in the pelvis and an irregular radiopaque mass in the urinary bladder (Fig. 1). A pelvic CT scan confirmed the hyperdense irregular mass with a T-shape in the bladder lumen measuring 5.5 cm along its longest axis on the posterior wall of the bladder, and diffuse urinary bladder wall thickening was noted (Fig. 2). A bone window view of the CT reveals the concentric calcification of the calculus around a foreign body, which resembles a copper IUD (Fig. 3a and b).

Fig. 1

Initial Kidney-Ureter-Bladder (KUB) X-ray. Plain KUB X-ray showing a an irregular hyperdense structure in the pelvis, surrounded by a dense radio-opaque shadow consistent with a bladder calculus

Fig. 2

CT scan showing an large hyperdense intravesical calculus. Axial CT image (soft tissue window) shows a large hyperdense calcified calculus in the urinary bladder with surrounding bladder wall thickening (red arrows)

Fig. 3

CT imaging (bone window) showing an intravesical stone formation around an IUD. (a) Axial CT image (bone window) showing a large, intravesical mass with concentric calcifications with a central linear hyperdense structure consistent with an IUD. (b) Sagittal CT image (bone window) reveals the typical T-shape of the copper IUD encrusted in a calcified calculus

Surgical intervention via open cystolithotomy was planned for January 2024 under general anesthesia. However, preoperative blood tests in January 2024 showed anemia again, with a Hemoglobin of 9.9 g/dL, a Hemocrit of 31.7%, and an RBC count of 3.63 million/µL, confirming the Patient’s history of an active process of blood loss due to her gross hematuria. Table 1 highlights the timeline of clinical events related to the Patient’s history.

Table 1 Clinical timeline of the patient

Upon exploration of the bladder lumen, a calculus, approximately 5.5 cm, was located and evacuated (Fig. 4a). The irregular shape was suspicious for a foreign body. The calculus was opened, revealing a copper IUD in its core (Fig. 4b).

Fig. 4

Gross appearance of the extracted intravesical calculus. (a) Gross specimen of the retrieved bladder stone exhibiting the typical (T) shape of the copper IUD. (b) Bisection of the stone reveals the embedded copper IUD which acted as the nidus from calculus formation with apparent concentric calcification

Postoperatively, the patient remained hospitalized for four days with a urinary catheter in place and was started on ceftriaxone 1000 mg IV every 12 h and metronidazole 500 mg three times daily. Empiric broad-spectrum antibiotic therapy was initiated to manage the UTI. Once E. coli was identified as the causative pathogen and antibiotic sensitivity results became available, the treatment was adjusted, and the patient was switched to Amikacin 500 mg twice daily. The patient’s hospital stay was free from any postoperative complications, and a discussion with the patient on why she presented late and ignored several key warning signs for IUD migration identified a gap in patient education and poor follow-up due to low socioeconomic status. She was discharged with follow-up plans to be reviewed in the urology outpatient clinic within one month.

On follow-up, she reported returning to her usual state of health with no UTIs or any LUTS, and routine blood tests were normal. Future contraceptive plans were discussed with the patient, and she expressed her intentions to remove the currently placed IUD, which was inserted following the presumed expulsion of the first IUD. She plans to conceive and, therefore, has opted against long-term contraceptive methods.

Discussion and conclusion

Intrauterine devices (IUDs), in all of their forms, are one of the longest-acting reversible contraceptive methods. They are considered among the most effective, safe, and accessible forms of birth control [6, 7]. Overall, IUDs have a very low rate of side effects of about 0.08% for the copper-containing IUD [8]; out of these side effects, the most dangerous one is the migration of an IUD into nearby structures. Several mechanisms associated with IUD migration and perforation have been theorized, but the two most accepted mechanisms are acute traumatic IUD perforation, which occurs immediately after insertion. Secondly, late inflammatory IUD perforation occurs due to gradual erosion and pressure necrosis through the uterine wall [7, 9]. Several risk factors have been identified which contribute to IUD perforation through the uterine wall. Similar to our case, first-time IUD users were at a higher risk for perforation than individuals who had used an IUD previously [10, 11]. Prior vaginal delivery was a protective factor against migration [10]. However, in our case, the patient had her first IUD inserted after her first vaginal delivery, and it subsequently migrated. The duration of time taken since IUD insertion and the onset of migration warning signs is critical to note in order to establish a temporal relationship between perforation and diagnosis. Evidence shows that about 69% of perforations were diagnosed within one year of insertion, while a small proportion of perforations were diagnosed immediately after IUD insertion [7, 10]. We can roughly estimate that the migration and the onset of urinary symptoms occurred in 2019, five years after the initial IUD insertion.

This case is a rare presentation due to the time taken from initial insertion until postoperative discovery. IUDs can rarely migrate to nearby structures, and according to the literature, common sites of migration include the abdomen: 12% to the greater omentum, 12% to the rectum, 9% to the sigmoid colon, 4% to the large bowel lumen, 5% ileum of the small intestines [12,13,14,15,16]. The sacral plexus, uterosacral ligament, and pouch of Douglas have been reported in case reports [16]. An additional site reported in the literature is the migration to the urinary bladder, as in this Patient’s case. The incidence of IUD migration is approximately 0.1-0.3%, with urinary bladder migration accounting for about 24% of all cases of IUD migration, according to the most recent systematic review [16, 17]. The site to which an IUD migrates causes local symptoms that can help physicians localize the pathology. Symptoms suggestive of IUD migration to the urinary bladder include dysuria, urinary frequency, gross hematuria, and a history of recurrent UTIs, which all were reported by our patient [7]. Scheduled follow-up appointments should be planned to check for the location of an IUD and ensure its correct position, as early detection of a migrated IUD in the bladder can prevent complications like bladder calculi and infections. Sometimes, delayed discovery occurs due to infrequent check-ups or a lack of awareness of migration warning signs. These warning signs are the new onset of LUTS, new onset pregnancy after IUD placement, or a missing IUD thread [6]. This patient’s unintentional pregnancy and recurrent infective and irritative LUTS and UTIs were warning signs of IUD migration to the bladder that should have been discovered earlier. However, the patient was not informed about spotting these symptoms and to return if any of these symptoms emerged. It is also important to note that the patient did not immediately seek medical attention for her symptoms, delaying the diagnosis. The patient inquired about the cause of her second pregnancy, knowing she was using an IUD as a contraceptive method. However, a presumption that is frequently reported is that even after the discovery that an IUD is missing, many physicians dismiss this finding as random IUD expulsion [18, 19]. Most importantly, it is a common practice to self-check for the thread of an IUD every 4–6 weeks as the first warning sign, and the most common reason for investigating an IUD location is a missing thread [6, 7, 18]. The patient was not informed about this practice, which could have prevented this rare clinical presentation and led to an earlier diagnosis. The diagnosis of IUD perforation is a challenging and complex process due to the insidious progression of nonspecific symptoms that are often associated with a broad differential diagnosis. Therefore, follow-up imaging of the device is needed to make a definitive diagnosis [7, 20]. If migrant IUDs are confirmed, prompt removal is indicated [14]. Ultrasonography is an appropriate method for the initial evaluation and can determine the correct position of the IUD [20]. Additionally, a KUB X-ray is usually indicated. However, abdominal and pelvic CT is the best modality for evaluating the accurate location of an IUD and associated complications [20,21,22]. In our case, KUB X-ray and CT imaging were promptly done, and a foreign body in the bladder was noted. Imaging may also fail to detect the IUD when bladder calculi form, as the dense calcification can obscure it, as noted in our patient’s CT scan [23]. Ultimately, the IUD was only confirmed postoperatively when the calculus was opened. The decision to remove a perforated IUD is controversial. However, it is almost always surgically managed by utilizing several techniques catered to each patient’s condition and other factors such as the position and shape of the calculus and hospital resources [23, 24]. IUDs that have migrated to the urinary bladder are generally treated with transurethral cystolitholapaxy [14, 21]. Other cases suggest less invasive procedures, such as the fragmentation of the cystoliths to a more manageable size using shockwave or laser lithotripsy and transurethral removal [23]. In this case, the unavailability of shock wave lithotripsy or other minimally invasive techniques, as they are offered by only one center in southern Palestine and not covered by the government-sponsored insurance program, was a key consideration. Given these resource constraints, open cystolithotomy became the most viable and feasible option for the patient at our government-funded hospital. Nevertheless, it provided immediate relief for the patient, as noted in other cases in the literature [25,26,27]. It is our recommendation that urologists and gynecologists alike should be aware of the fact that even though bladder calculi are rare among females, the use of an IUD in a patient with recurrent LUTS should suggest the presence of a migrated IUD among the differential diagnoses considered. It is essential that incidents of IUD expulsion be further investigated. Patients in Palestine should receive comprehensive education during IUD placement visits, including an overview of the potential risk factors associated with IUD use. Additionally, they should be informed on identifying warning signs of IUD migration. Moreover, additional training and updated physician guidelines are crucial to ensure effective patient monitoring. We emphasize the importance of patient education on the risks and signs of potential complications, and improved follow-up care to ensure early detection and management of any side effects. Lastly, we recommend more in-depth research to explore the risks and protective factors related to IUD migration, as well as the relationship between the type of IUD used and the risk of uterine perforation.