IUCD migration into the bladder: An unusual encounter with intravesical stone formation

A 45-year-old female patient who was para 2 with h/o IUCD insertion 2 years back, with complaints of severe lower abdomen pain and burning urination, arrived at the emergency room. Although the abdominal and vaginal inspection revealed no abnormalities, the IUCD thread was not visible. Patient was subjected to emergency abdominal ultrasound in view of missing IUCD thread.

On abdominal ultrasound (Figure 1a and 1b), IUCD was not visualised within the endometrial cavity. It was migrated and embedded in posteroinferior wall of urinary bladder with intravesical stone formation.

Patient was subjected to abdominal radiograph (Figure 2), revealing the IUCD in the region of urinary bladder with stone formation noted in the horizontal limb.

Further on, unenhanced CT abdomen (Figures 3a, 3b) revealed there is embedment of vertical limb into the posteroinferior wall of urinary bladder with intravesical calculus formation in one of the horizontal limbs. There was no fistulous tract between the uterus and urinary bladder. Fat planes between the urinary bladder and uterus were maintained. Cervix and vagina were unremarkable.

Cystoscopy images (Figures 4a and 4b) revealed vertical limb penetrating the bladder mucosa and one of the horizontal limbs covered with stone, which was removed successfully via cystoscopy.

Following the procedure, the patient was given two weeks of antibiotics and recovered well.

The IUCD is the widely used mode of contraception. Its associated complications include expulsion, displacement, perforation and penetration. The use of imaging is crucial in determining the difficulties that could result from the IUCD, such as low position, myometrium migration, uterine perforation, intrauterine, or ectopic pregnancy.

Uterine perforation and intravesical migration are exceedingly uncommon. After the IUCD enters the bladder, it typically develops calculus encrustation and is linked to symptoms of the lower urinary tract. The presentation of recurrent urinary tract infection after IUCD suggest an intravesical migration.

There are two possible pathways in the pathophysiology of uterine perforation of IUCD. First, during insertion, uterine perforation may happen, particularly if it is accompanied by excruciating stomach discomfort [3]. Second, a progressive pressure necrosis of the uterine wall by IUCD (probably at its lead point), with necessary migration out of the uterus, is the mechanism of perforation that is hypothesised.

US is the recommended modality for first imaging in patients with suspected perforation. It has been shown that three-dimensional ultrasound is very helpful in detecting implanted and malpositioned IUDs in symptomatic individuals [4]. The most helpful modality for determining intraabdominal IUCD problems is CT. When a patient is in an emergency, CT is commonly utilised to confirm US findings and rule out other possible causes of their symptoms.

There are no widely used surgical methods to address this problem. The best approaches to treat a misplaced IUCD with a good prognosis are minimally invasive procedures such as laparoscopy, hysteroscopy, and cystoscopy, alone or in combination [5–6].

This case highlights the importance of suspicion for intravesical migration of IUCD when patient gives a history of recurrent urinary tract infection and a history of missing threads of IUCD.

When there is evidence of intravesical migration, urology referral can be made and IUCD can be retrieved by cystoscopy or open method by midline laparotomy [1].

To conclude, any findings of IUCD mal positioning should be relayed to the medical professional by the radiologist. Expulsion, displacement, perforation IUCD should be reported right once to the patient and healthcare professional since they can reduce the effectiveness of the contraceptive method and may necessitate additional management. The patient's clinical presentation should be used as a starting point for any urgent surgical intervention, and cross-sectional imaging results intended as indicators for significant intraabdominal complications should also be considered.