
==== Front
IJU Case Rep
IJU Case Rep
10.1002/(ISSN)2577-171X
IJU5
IJU Case Reports
2577-171X
John Wiley and Sons Inc. Hoboken

10.1002/iju5.12753
IJU512753
IJUCR-2024-0062.R1
Case Report
Case Report
Vesicovaginal fistula and bladder calculus formation secondary to long‐term retention of an intrauterine device
Vesicovaginal fistula due to long‐term IUD use
M Goto et al.
Goto Masahiro 1
Kaneko Tomoyuki https://orcid.org/0000-0002-5762-7563
1 kanekot-tky@umin.ac.jp

Yamamine Naoki 1
Yanagida Kazuki 1
Noda Michio https://orcid.org/0000-0002-7515-7358
1
Tokura Yuumi 1
Yoshimura Itsuki 1
Kawai Taketo https://orcid.org/0000-0002-7279-2874
1
Nakagawa Tohru https://orcid.org/0000-0003-4041-7241
1
1 Department of Urology Teikyo University School of Medicine Tokyo Japan
* Correspondence: Tomoyuki Kaneko M.D., Department of Urology, Teikyo University School of Medicine, 2‐11‐1, Kaga, Itabashi‐ku, Tokyo 173‐8605, Japan. Email: kanekot-tky@umin.ac.jp

16 6 2024
9 2024
7 5 10.1002/iju5.v7.5 355358
29 3 2024
04 6 2024
© 2024 The Author(s). IJU Case Reports published by John Wiley & Sons Australia, Ltd on behalf of Japanese Urological Association.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

Introduction

Although uterine perforation is a rare but serious complication, intrauterine devices are globally popular and effective contraceptive methods.

Case presentation

A 76‐year‐old female patient manifesting symptoms of vaginal leakage and lower abdominal discomfort was admitted to our hospital. Diagnostic imaging identified a vesicovaginal fistula and bladder calculi attributable to perforation of the bladder by an intrauterine device that had been inserted over four decades ago. The patient underwent open surgery for cystolith removal and vesicovaginal fistula repair.

Conclusions

If a patient with an intrauterine device complains of bladder stones or ongoing lower urinary tract symptoms, bladder perforation caused by the device should be considered in the differential diagnosis.

intrauterine device migration
intrauterine devices
urinary bladder calculi
uterine perforation
vesicovaginal fistula
source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:01.09.2024
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pmcAbbreviations & Acronyms

CT computed tomography

IUD intrauterine device

Keynote message

Uterine perforation induced by an intrauterine device is an infrequent yet grave complication. If a patient with a history of intrauterine device implantation presents with the predominant symptoms of bladder stones or enduring lower urinary tract issues, bladder perforation of the intrauterine device should be considered in the differential diagnosis.

Introduction

IUDs are the leading choice for reversible contraception globally, known for their high safety, effectiveness, and ease of use. 1 They offer long‐term birth control and reduce the need for daily attention. However, although adverse effects of IUDs are rare, they can occur during or after insertion, including device expulsion, pelvic inflammatory disease, contraceptive failure, and uterine perforation. 2 , 3 , 4 , 5 Uterine perforation is a severe complication. Following such a perforation, migration of the IUD to the omentum, rectosigmoid colon, peritoneum, appendix, intestine, and bladder may occur. 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 We present a case involving the development of a vesicovaginal fistula and bladder calculus attributed to a neglected IUD that had been in situ for >40 years, necessitating open surgical removal of the IUD and repair of the vesicovaginal fistula.

Case report

A 76‐year‐old female presented to the hospital with persistent symptoms of frequent urination, urinary incontinence, and lower abdominal pain that had persisted for several months. Abdominal radiography and ultrasonography revealed a bladder calculus 4 cm in diameter. Elective cystolithotripsy was considered; however, preoperative CT imaging raised concerns about bladder perforation, which is potentially caused by an intrauterine foreign body concurrent with the bladder calculus. A subsequent detailed history elicitation revealed the insertion of an IUD over four decades ago, which had remained in situ. Given the complexity of the case, the patient was referred to our Department of Urology for further management. At the initial consultation, the patient presented with continuous urinary leakage through the vagina, necessitating the use of a diaper. She also reported persistent pelvic pain for several months. The patient had a history of four pregnancies, including two vaginal deliveries and one abortion. There was no history of cesarean section. She experienced menopause at the age of 50. There were no other significant findings in her medical or social history. Diagnostic imaging including plain abdominal radiography revealed an IUD superimposed on the bladder stone (Fig. 1a). Further evaluation with non‐contrast CT of the abdomen revealed that the IUD arm had penetrated the posterior bladder wall, leading to bladder stone formation (Fig. 1b,c). Surgical intervention involved open cystolithotomy and vesicovaginal fistula repair. Intraoperatively, upon cystotomy, a calculus was identified at the neck of the urinary bladder (Fig. 2a). After applying traction to the stone using grasping forceps, the stone was successfully and smoothly extracted along with the IUD. Following stone removal, inspection of the bladder revealed a fistula 2 cm in diameter situated between the bilateral ureteral orifices and the vaginal lumen. Owing to the proximity of the fistulas to the bilateral ureteral orifices, ureteral stents were placed within both ureters (Fig. 2b). The vesicouterine pouch was dissected dorsally away from the bladder to reveal a fistula extending from the cervix to the anterior vaginal wall. The fistula located on the anterior vaginal wall was repaired using continuous sutures of 2‐0 Vicryl, whereas the fistula in the bladder wall was closed in a two‐layered fashion using continuous sutures of 3‐0 Monocryl followed by 2‐0 Monocryl. The removed specimen revealed a calculus that developed around one arm of the T‐shaped IUD (Fig. 2c). The patient did not develop any postoperative complications. The urethral catheter was removed on postoperative day 13, the ureteral stents were extracted on postoperative day 16, and the patient was discharged on postoperative day 20.

Fig. 1 (a) Plain abdominal radiograph showing a bladder stone, indicated by a black arrowhead, and an overlying IUD, indicated by a white arrowhead. (b) Non‐contrast horizontal section and (c) sagittal section of an abdominal CT scan showing penetration of one arm of the IUD into the bladder, indicated by a white arrowhead, with stone formation at the tip, indicated by a black arrowhead.

Fig. 2 (a) Intraoperative photograph showing a stone at the bladder neck, indicated by a black arrowhead. (b) Subsequent intraoperative photograph after stone removal, showing a fistula between the bilateral ureteral openings, indicated by a white arrowhead, which necessitated the insertion of bilateral ureteral stents. (c) The specimen displays a calculus, indicated by a black arrowhead, formed around one arm of the T‐shaped IUD, indicated by a white arrowhead.

Discussion

There are two primary types of IUDs: copper‐containing and hormone‐releasing (Fig. 3a–c). IUDs have become a widely favored contraceptive method globally because of their effectiveness and low incidence of complications. According to 2019 United Nations estimates, among women of reproductive age, global usage of IUDs is documented at 8.4%. 1 Notable regional variances are observed, with utilization rates reaching as high as 46.9% in Democratic People's Republic of Korea, 36% in Uzbekistan, and 30.8% in Turkmenistan. 1 Meanwhile, the adoption rates in the United States and Europe are significantly lower, at 8.3% and 8.1%, respectively. 1 The prevalence of IUD utilization in Japan is notably low, with a reported rate of 0.4%. 1

Fig. 3 (a) An image of the levonorgestrel‐releasing intrauterine system (Levonorgestrel 52 mg; Mirena®, Bayer, Germany). (b) An image of a copper‐bearing IUD (NOVA‐T380®, Bayer, Germany). (c) An image of a levonorgestrel‐releasing intrauterine system attached to a special inserter.

Uterine perforation is a significant risk factor for IUD use. The frequency of this complication is estimated to vary between 0.3 and 2.6 instances for every 1000 IUD placements. 2 , 3 , 4 , 5 Several factors that increase the risk of uterine perforation have been identified. Being in the recent postpartum state and breastfeeding are associated with a heightened risk of perforation. 2 , 3 , 4 , 5 Additional risk factors include the inexperience of the healthcare provider carrying out the procedure, having had multiple pregnancies, having no previous pregnancies, and a history of cesarean delivery. 2 , 3 , 4 , 5 The majority of uterine perforations transpire at the moment of IUD insertion; however, in exceptional instances, they can result from extended erosion of the myometrium, culminating in uterine perforation and subsequent extrauterine migration. The documented locations of extrauterine migration include the omentum, broad ligament, rectosigmoid colon, peritoneum, adnexa, and iliac vein. 2 , 3 , 4 , 5

The accepted method for treating a misplaced IUD involves surgical removal through laparoscopy or laparotomy. 2 , 3 , 4 , 5 Both the World Health Organization and International Medical Advisory Panel Meetings of the International Planned Parenthood Federation advise that an IUD that has moved from its original position should be removed as quickly as possible once the diagnosis is confirmed, regardless of the type of IUD or where it ended up. 12 , 13 Removal of an IUD from the bladder requires careful consideration of its position, shape, patient conditions, and available hospital equipment. If the IUD partially perforates the bladder wall, and its string remains accessible through the vagina, attempts should be made to remove it vaginally. If the IUD is completely or largely within the bladder, cystoscopy can be employed for its removal, which is the resolution in most reported cases. 6 , 7 When part of the IUD lies intraperitoneally, laparoscopy or a combination of laparoscopy and cystoscopy may be utilized. 8 However, if these approaches prove challenging, as in this case, open surgery may become necessary. 9 To the best of our knowledge, there have been only three reported cases of vesicovaginal fistula attributable to IUD usage. 9 , 10 , 11 One patient underwent laparotomy, while the IUDs were removed transurethrally in the other two patients. Among them, one refused additional treatment, and the other patient was referred to a gynecologist for the treatment of a vesicovaginal fistula. 9 , 10 , 11 Regarding the management of IUDs, routine follow‐up examinations are not mandated unless specific concerns arise. 14 Nevertheless, it is crucial to adhere to the prescribed replacement schedules for each IUD type, as these devices have designated lifespans after which their effectiveness can diminish and risk of complications may increase.

In conclusion, we encountered a case of vesicovaginal fistula and bladder stones attributed to a long‐standing IUD. When a patient with a history of IUD implantation presents with refractory urinary tract infection, persistent lower urinary tract symptoms, or bladder stones, bladder perforation of the IUD should be considered in the differential diagnosis. Given the rarity of such cases, urologists must be vigilant about these issues.

Author contributions

Masahiro Goto: Data curation. Tomoyuki Kaneko: Conceptualization; data curation; writing – original draft. Naoki Yamamine: Data curation. Kazuki Yanagida: Data curation. Michio Noda: Data curation. Yuumi Tokura: Data curation. Itsuki Yoshimura: Data curation. Taketo Kawai: Writing – review and editing. Tohru Nakagawa: Supervision; writing – review and editing.

Conflict of interest

The authors declare no conflict of interest.

Approval of the research protocol by an Institutional Reviewer Board

Not applicable.

Informed consent

Written informed consent was obtained from the patient.

Registry and the Registration No. of the study/trial

Not applicable.
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