Intrauterine contraceptive device-induced vesicolithiasis: A tomb stone

INTRODUCTION

Intrauterine contraceptive device (IUCD) has been known to be one of the effective accepted methods of contraception worldwide, including in Nigeria.^[1-3] It has an acceptance rate range between 47% and 66%.^[4] There are untoward risks related to IUCD use such as discomfort after insertion, infection, and uterine perforation with low-risk ranges from 0.3 to 2.2/1000 insertions.^[5-7]

Bladder calculi constituents are calcium oxalate, calcium phosphate, ammonium urate, magnesium, uric acid, cysteine, and others.^[8] It can be caused by bladder outlet obstruction, chronic or recurrent infections, and presence of foreign body in the bladder.^[9] A migrated IUCD is a rare cause of bladder calculi.^[10] The most common sites for IUCD migration are the omentum, rectum, sigmoid colon, peritoneum, and bladder.^[11] This report discusses the clinical case presentation, diagnostic evaluation, and management modality.

CASE REPORT

A 40-year-old woman presented to the urology clinic with recurrent lower abdominal pain for 12 years duration. The lower abdominal pain was first noticed 3 months post insertion of an IUCD at a maternity home with the pain described as moderate, dull aching, intermittent, radiating to the vulva, aggravated by changes in position with no relieving factor. The pain progressively worsened disturbing her routine activities hence her presentation.

There were associated lower urinary tract symptoms of mainly frequency and urgency, with observed crystalluria. There was no hematuria,urinary retention and history suggestive of renal compromise.

She had presented at various health facilities and was managed for recurrent urinary tract infections with little improvement in symptoms.

She had no comorbidity and no prior surgery.

She has four children. She had placement of IUCD post-delivery after each pregnancy previously. She had her last two deliveries 5 years and 2 years post IUCD insertion, respectively.

Examination revealed a young woman in good general condition. Her pulse rate, respiratory rate and blood pressure were within normal limit. Abdominal examination revealed suprapubic tenderness. Hematology investigation was within normal limit. Urinalysis revealed leucocytes. An abdomino-pelvic ultrasound scan done showed a solitary ill-defined mass casting posterior acoustic shadow located in the bladder suggestive of a solitary bladder calculus. Furthermore, a plain radiograph showed a single ill-defined radio-opacity in the pelvis as shown below . [Figure 1]

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Figure 1:

X-ray of the pelvis showing the intrauterine contraceptive device at the polar aspect of the opacity in the pelvis.

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The diagnosis of bladder stone secondary to IUCD was made. She was worked up and had open cystolithotomy through a suprapubic skin crease incision.

Intraoperative findings were urinary bladder with cloudy urine, normal bladder wall thickness, and a 6 × 8 cm rough surfaced bladder stone with a calcified IUCD at the summit.

Stone was removed and bladder was copiously irrigated with normal saline.

Subsequently, 2-way Silicon urethral catheter 16Fr was passed and urinary bladder wall closed into two layers. Wound closure was done in layers.

Patient was placed on antibiotics and analgesics postoperatively. She did well and was discharged on postoperative day (POD) 2, post-operative recovery was satisfactory, and removal of catheter was done in clinic on POD 10 . [Figure 2-3]

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Figure 2:

Intraoperative picture depicting the open cystostomy with a bladder stone in situ.

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Figure 3:

Urinary bladder stone with calcified intrauterine contraceptive device at the summit.

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DISCUSSION

The presence of IUCD in the bladder is a rare occurrence and this can be either due to a perforation of the uterus with device migration anteriorly, or wrong placement of the device through the urethral at the time of IUCD insertion.^[12] Studies have shown that wrong placement of IUCD occurs in 0–1.6/1000 insertions.^[12] A case of a sigmoid colocolic fistula due to an intraperitoneal IUCD was reported by Weerasekera et al.^[13] However, intravesical migration of IUCD culminating into bladder calculi has been reported in several studies.^{[1,2,4,11,12]} In this index patient, IUCD was found in the urinary bladder and she did not palpate the string of the device in the vagina after insertion. Regular feeling of the IUCD string after insertion is very paramount, which is being neglected by many patients. This will facilitate early recognition and prompt intervention if there be a misplaced IUCD after insertion.^[14] Radiological imaging, such as pelvic ultrasound and pelvic X-ray can confirm the diagnosis.^[12,14]

The risk factors for migrated IUCD such as previous cesarean delivery, immediate postpartum, and post-abortal insertion, have been documented,^[15,16] but these were not noted in this index case. Conversely, none of these mentioned risk factors were found in this index patient. However, a raised suspicion of a wrong placement of IUCD device per urethral was considered.

The clinical presentations of vesicolithiasis from IUCD range from the patient being asymptomatic or having storage lower urinary tract symptoms (LUTS) (such as frequency and urgency), painful micturition, hematuria and suprapubic pain, or incontinence.^[16,17] The symptoms in the index patient were storage LUTS and suprapubic pain.

There are different treatment options for bladder calculi from migrated IUCD, which include minimally invasive techniques or open surgical interventions. The determinant factors for choice of treatment may depend on stone size, surgeon expertise, and equipment available in the facility.^[14] The minimal invasive options include transurethral or percutaneous cystoscopic removal (cystolitholapaxy),^[14,15,18] lithotripsy^[19] (laser, shock-wave, ultrasonic, pneumatic, or mechanical), or transvesical laparoendoscopy which are usually for small stone <2 cm^{[14,15,20,21]} Robotic surgery can be done for large bladder calculi where it is available^[21,22]

Open cystolithotomy is the preferred choice for large bladder calculi^[14,21] which was the option of treatment done for this patient. Ago and Enakirerhi and Adeyanju et al. had similar large bladder calculi and they opted for open cystolithotomy.^[14,21]

CONCLUSION

IUCD is a globally accepted form of contraception, after its insertion, it requires appropriate monitoring of the device position and insertion should be done by trained health personnel. However, if there is any dislodgement or migration as seen rarely early presentation and urgent intervention will prevent adverse event such as bladder calculi formation and its complications.