Diu migracion intravesical 6 casos int urogynecol j_pelvic_floor_dysfunct._2007_may_18(5)_575-8 2007
Int Urogynecol J (2007) 18:575–578DOI 10.1007/s00192-006-0157-z CASE REPORTIntravesical migration of an intrauterine contraceptivedevice complicated by bladder stone: a report of six casesYassine Nouira & Salah Rakrouki & Mourad Gargouri &Zouhaier Fitouri & Ali HorchaniReceived: 20 March 2006 / Accepted: 15 May 2006 / Published online: 21 June 2006# International Urogynecology Journal 2006Abstract Intrauterine contraceptive device is the most Case reportspopular method of reversible contraception in developingcountries due to its efficiency and low cost. However, this Case 1device is often inserted by paramedics of variable skills, andfollow-up evaluations are irregular or absent which can be the A 42-year-old woman in a family planning centre had ansource of major complications. The authors report six cases of IUCD inserted 10 years ago. She did not receive annualintravesical migration of intrauterine contraceptive devices gynaecological exams and had two unattended labours withoutcomplicated by bladder stones. All the six cases were IUCD removal. This patient presented for a 5-year history ofmanaged endoscopically with excellent outcome. The authors lower abdominal pain, burning micturition and frequency.demonstrate that this major complication can be managed Examination revealed a mobile mass through the anteriorendoscopically with decreased morbidity for the patient. vaginal wall. Plain X-ray film of the pelvis revealed a T-shaped IUCD embedded in a bladder stone. Cystoscopy confirmed theKeywords Intrauterine contraceptive device . Bladder . diagnosis of a bladder stone mobile in the bladder with intactPerforation . Migration . Stone bladder mucosa. The stone was fragmented endoscopically using a ballistic lithotripter (Swiss Lithoclast, Le Sentier, Switzerland), and the IUCD was extracted.Introduction Case 2Urinary bladder foreign bodies can constitute a nidus ofcrystallization for bladder stones [1, 2]. Intrauterine contracep- A 37-year-old woman presented with irritative voidingtive device migration into the bladder is a rare event. Patients symptoms and recurrent urinary tract infections. Thismay present with irritative voiding symptoms, hematuria and patient had these symptoms for 6 months and was treatedrecurrent urinary tract infection. We report six cases of empirically with antibiotics elsewhere. Five years before,intrauterine copper-T contraceptive devices (IUCDs) migrating she had IUCD placed without complications. Physicalto the bladder complicated by bladder stone formation. examination was unremarkable. Plain radiograph of the pelvis revealed a 1-cm stone forming on the long arm of the T-shaped IUCD. Intravenous urography showed this part of the IUCD to be intravesical. Cystoscopy confirmed theY. Nouira (*) : S. Rakrouki : M. Gargouri : Z. Fitouri : diagnosis of partially intravesical IUCD complicated with aA. HorchaniDepartment of Urology, La Rabta Hospital, stone. With endoscopic crocodile forceps (Storz, Tuttlingen,Tunis, Tunisia Germany), the stone was grasped, and gentle traction on ite-mail: email@example.com allowed complete extraction of the IUCD with the stone (Fig. 1).Y. Nouira5 Rue Ibn Messaoud, El Menzah 6, A punctate bladder perforation was present at the end of2091 Ariana, Tunisia the procedure, and we decided to manage it conservatively.
576 Int Urogynecol J (2007) 18:575–578 the patient presented for frequency, burning micturition and total hematuria 9 months in duration. A plain film of the kidney, ureter and bladder revealed that she had a T-shaped IUCD with a 3-cm stone developed on its long arm. Intravenous urography showed the stone to be intravesical (Fig. 2). The patient was managed endoscopically with ballistic fragmentation of the stone and extraction of the IUCD cystoscopically. The patient’s recovery was unre- markable, given a 10-day urinary drainage of the bladder by an indwelling catheter. Case 5 In 1997, a 26-year-old woman had an IUCD inserted by a midwife in a family planning centre. In 2003, this patient presented for recurrent lower urinary tract infections lasting for 6 months. Plain radiograph of the pelvis revealed a 5-mm stone forming on one short arm of the T-shaped IUCD. Intravenous urography confirmed the diagnosis of calcified,Fig. 1 A stone forming on the long arm of the copper-T intrauterine partially intravesical IUCD. On cystoscopy, one arm of thecontraceptive device IUCD emerged in the bladder lumen at the bladder dome.The patient had an indwelling transurethral catheter for Using an endoscopic forceps, the IUCD was extracted10 days with excellent outcome. cystoscopically. However, despite gentle traction, the device was broken during the procedure, and a 1-cm fragment of theCase 3 long arm of the T-device was left in place. Ultrasonography showed this fragment to be outside the uterine cavity.A 38-year-old woman had an IUCD inserted by a midwife Urinary drainage by an indwelling catheter was maintained9 years ago. She had not attended any follow-up visits after for 10 days. Postoperative course was uneventful. With athe implantation of the device, including the 1-month check 2-year- follow-up, the patient was doing well, and thefor the string. Three years later, she delivered a child IUCD fragment did not migrate to the bladder. The patientwithout the removal of the device. Her pregnancy was not was advised to attend annual outpatient visits and to seekmedically followed up, and she did not give any mention of medical advice if irritative voiding symptoms recur. Futurethe already existing contraceptive device to the midwifewho was following up her in a primary care health unit.This patient was referred to our urological department formanagement of a 3-year recurrent lower urinary tractinfection and episodes of terminal hematuria. Intravenousurography showed a migrating T-shaped IUCD with a 1-cmbladder stone developing on one arm of the device.Cystoscopy showed that the device was partially intra-vesical. The stone was fragmented with a ballistic litho-tripter, and the IUCD was extracted using a forceps. Thepatient was discharged on the first postoperative day, withan indwelling bladder catheter that was removed on thepostoperative day 10. The patient had an excellent recovery.Case 4In 1990, a 30-year-old woman, mother of four children, hadan IUCD inserted by a paramedic in a family planningcentre. Apart from the 1-month check for the string, the Fig. 2 Oblique view of cystogram showing a 3-cm bladder stonepatient failed to have her device medically controlled. In (arrowheads) formed on a partially intravesical migrating contracep-2001, when she had already given birth to her fifth child, tive device
Int Urogynecol J (2007) 18:575–578 577progression of the IUCD fragment into the bladder will however, some remain undiagnosed for several years .allow its cystoscopic retrieval. Experience of the practitioner is a crucial element in determining the risk of uterine perforation. It was shownCase 6 in a large-scale study that doctors who reported inserting less than ten devices reported significantly more perfo-A 40-year-old woman was referred to urology for frequency rations than those who reported inserting between 10and lower abdominal pain 1 year in duration. Her past and 100 devices . These findings stress the fact thatobstetrical history included three normal vaginal deliveries. placing an IUCD is an invasive procedure and should beShe had an IUCD inserted by a paramedic 4 years ago. Pelvic performed by experienced doctors. It is not surprising thatultrasonography showed the IUCD to be partly intravesical in the cases we report, the device was placed by paramedics(Fig. 3). Cystoscopy showed a 10-mm stone on one arm of with varying skills, in family planning facilities, and inthe IUCD that was partly intravesical. Gentle traction on the rural areas.stone allowed complete extraction of the device cystoscop- In the cases we report, we think migration to the bladderically. Postoperative course was uneventful. was progressive and facilitated by endometrial inflamma- tion and enzyme liberation induced by the copper-T intrauterine device. However, we believe that for an IUCDDiscussion to become embedded in the myometrium and subsequently migrate outside the uterus, some degree of uterine wallIntrauterine device is the most popular method of reversible damage is a major contributing element. That is why, wecontraception  due to its efficiency and low cost. In think that a technical problem during insertion shoulddeveloping countries, it is often inserted by paramedics always be incriminated in these cases.with variable skills, and follow-up evaluations are irregular An IUCD in the bladder can also be the consequence ofor absent as in the cases we report. One of the major, inserting it erroneously in the bladder through the urethraalthough infrequent, complications of IUCD is perforation . In the first case we report, cystoscopy showed a totallythrough the uterine wall into the pelvic or abdominal cavity. mobile T-shaped bladder stone covering the IUCD with noIn a literature review by Kassab and Audra , a total of mucosal lesions. These findings can be consistent either165 cases of migrating IUCDs were collected, and only 23 with an early bladder perforation during insertion of thewere in the bladder (14%). Incidence of uterine perforation device or an erroneous placement of the IUCD directly inwas reported to be 1.6 for 1,000 insertions . Most the bladder by an inexperienced paramedic lacking basicperforations are diagnosed at the time of insertion (86% of anatomical knowledge.cases) suggested by pain, bleeding or a lost thread; Calculus formation is due to calcium precipitation on the device that plays the role of matrix [1, 2]. Although ultrasonography is an excellent diagnostic tool in cases of lost IUCD , partial migration in the bladder can be difficult to be recognised by ultrasonography alone. This makes cystoscopy the optimal approach to diagnose and to manage IUCD migrating to the bladder. All IUCDs migrating to the bladder should be removed. Unlike previously reported cases , we opted for endoscopic management in all our patients. This was done because of minimal invasiveness concern and because endoscopic management does not prevent conversion to open surgery should it be a failure. Endocorporeal lithoripsy and IUCD extraction were easily performed in our cases. Because the partially migrating IUCD was either under the bladder mucosa or within the bladder wall, gentle traction on it allowed its complete extraction in four out of the five cases of partial migration in our patients. The punctate bladder perforation caused by pulling the IUCD out of the bladder wall was insignificant and healed simply by prolonged urinary drainage.Fig. 3 Transvaginal ultrasonography showing an IUCD perforating The cases we report show that open surgery is avoidablethe dome of the bladder complicated by a bladder stone in the management of these iatrogenic lesions.
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