1. Int Urogynecol J (2007) 18:575–578
DOI 10.1007/s00192-006-0157-z
CASE REPORT
Intravesical migration of an intrauterine contraceptive
device complicated by bladder stone: a report of six cases
Yassine Nouira & Salah Rakrouki & Mourad Gargouri &
Zouhaier Fitouri & Ali Horchani
Received: 20 March 2006 / Accepted: 15 May 2006 / Published online: 21 June 2006
# International Urogynecology Journal 2006
Abstract Intrauterine contraceptive device is the most Case reports
popular method of reversible contraception in developing
countries due to its efficiency and low cost. However, this Case 1
device is often inserted by paramedics of variable skills, and
follow-up evaluations are irregular or absent which can be the A 42-year-old woman in a family planning centre had an
source of major complications. The authors report six cases of IUCD inserted 10 years ago. She did not receive annual
intravesical migration of intrauterine contraceptive devices gynaecological exams and had two unattended labours without
complicated by bladder stones. All the six cases were IUCD removal. This patient presented for a 5-year history of
managed 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 anterior
endoscopically 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 the
Keywords Intrauterine contraceptive device . Bladder . diagnosis of a bladder stone mobile in the bladder with intact
Perforation . 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 2
Urinary bladder foreign bodies can constitute a nidus of
crystallization for bladder stones [1, 2]. Intrauterine contracep- A 37-year-old woman presented with irritative voiding
tive device migration into the bladder is a rare event. Patients symptoms and recurrent urinary tract infections. This
may present with irritative voiding symptoms, hematuria and patient had these symptoms for 6 months and was treated
recurrent 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. Physical
to 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 the
Y. Nouira (*) : S. Rakrouki : M. Gargouri : Z. Fitouri :
diagnosis of partially intravesical IUCD complicated with a
A. Horchani
Department of Urology, La Rabta Hospital, stone. With endoscopic crocodile forceps (Storz, Tuttlingen,
Tunis, Tunisia Germany), the stone was grasped, and gentle traction on it
e-mail: nouirayassine@gnet.tn allowed complete extraction of the IUCD with the stone
(Fig. 1).
Y. Nouira
5 Rue Ibn Messaoud, El Menzah 6, A punctate bladder perforation was present at the end of
2091 Ariana, Tunisia the procedure, and we decided to manage it conservatively.

2. 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 the
contraceptive 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 extracted
10 days with excellent outcome. cystoscopically. However, despite gentle traction, the device
was broken during the procedure, and a 1-cm fragment of the
Case 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 maintained
9 years ago. She had not attended any follow-up visits after for 10 days. Postoperative course was uneventful. With a
the implantation of the device, including the 1-month check 2-year- follow-up, the patient was doing well, and the
for the string. Three years later, she delivered a child IUCD fragment did not migrate to the bladder. The patient
without the removal of the device. Her pregnancy was not was advised to attend annual outpatient visits and to seek
medically followed up, and she did not give any mention of medical advice if irritative voiding symptoms recur. Future
the already existing contraceptive device to the midwife
who was following up her in a primary care health unit.
This patient was referred to our urological department for
management of a 3-year recurrent lower urinary tract
infection and episodes of terminal hematuria. Intravenous
urography showed a migrating T-shaped IUCD with a 1-cm
bladder 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. The
patient was discharged on the first postoperative day, with
an indwelling bladder catheter that was removed on the
postoperative day 10. The patient had an excellent recovery.
Case 4
In 1990, a 30-year-old woman, mother of four children, had
an IUCD inserted by a paramedic in a family planning
centre. Apart from the 1-month check for the string, the Fig. 2 Oblique view of cystogram showing a 3-cm bladder stone
patient 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

3. Int Urogynecol J (2007) 18:575–578 577
progression of the IUCD fragment into the bladder will however, some remain undiagnosed for several years [5].
allow its cystoscopic retrieval. Experience of the practitioner is a crucial element in
determining the risk of uterine perforation. It was shown
Case 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 10
and lower abdominal pain 1 year in duration. Her past and 100 devices [5]. These findings stress the fact that
obstetrical history included three normal vaginal deliveries. placing an IUCD is an invasive procedure and should be
She had an IUCD inserted by a paramedic 4 years ago. Pelvic performed by experienced doctors. It is not surprising that
ultrasonography 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 in
the 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 bladder
ically. 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 IUCD
Discussion to become embedded in the myometrium and subsequently
migrate outside the uterus, some degree of uterine wall
Intrauterine device is the most popular method of reversible damage is a major contributing element. That is why, we
contraception [3] due to its efficiency and low cost. In think that a technical problem during insertion should
developing 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 of
or absent as in the cases we report. One of the major, inserting it erroneously in the bladder through the urethra
although infrequent, complications of IUCD is perforation [6]. In the first case we report, cystoscopy showed a totally
through the uterine wall into the pelvic or abdominal cavity. mobile T-shaped bladder stone covering the IUCD with no
In a literature review by Kassab and Audra [4], a total of mucosal lesions. These findings can be consistent either
165 cases of migrating IUCDs were collected, and only 23 with an early bladder perforation during insertion of the
were in the bladder (14%). Incidence of uterine perforation device or an erroneous placement of the IUCD directly in
was reported to be 1.6 for 1,000 insertions [5]. Most the bladder by an inexperienced paramedic lacking basic
perforations 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 [7], 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 [8], 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 avoidable
the dome of the bladder complicated by a bladder stone in the management of these iatrogenic lesions.

4. 578 Int Urogynecol J (2007) 18:575–578
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