Using laparoscope to remove an ectopic intrauterine device in the anterior wall of urinary bladder: A case report

Abstract

BACKGROUND

An intrauterine device (IUD) is a contraceptive device placed in the uterine cavity and is a common contraceptive method for Chinese women. However, an IUD may cause complications due to placement time, intrauterine pressure and other factors. Ectopic IUDs are among the most serious complications. Ectopic IUDs are common in the myometrium and periuterine organs, and there are few reports of ectopic IUDs in the urinary bladder, especially in the anterior wall.

CASE SUMMARY

A 52-year-old woman was hospitalized due to a urinary bladder foreign body found via abdominal ultrasound and computed tomography (CT) examination. The patient had a 2-year history of recurrent abdominal distension and lower abdominal pain, accompanied by frequent urination, urgency, dysuria and other discomfort. Ultrasound examination revealed foreign bodies in the bladder cavity, with calculus on the surface of the foreign bodies. CT revealed a circular foreign body on the anterior wall of the urinary bladder, suggesting the possibility of an ectopic IUD. After laparoscopic exploration, an annular IUD was found in the anterior wall of urinary bladder, and an oval calculus with a diameter of approximately 2 cm was attached to the surface of the bladder cavity. The IUD and calculus were successfully and completely removed. The patient recovered well after surgery.

CONCLUSION

Abdominal ultrasound and CT are effective methods for detecting ectopic IUDs. The IUD is located in the urinary bladder and requires early surgical treatment. The choice of surgical method is determined by comprehensively considering the depth of the IUD in the bladder muscle layer, the situation of complicated calculus, the situation of intravesical inflammation and medical technology and equipment.

Key Words: Intrauterine device, Ectopic, Anterior wall of the urinary bladder, Calculus, Laparoscope, Case report

Core Tip: There are few reports of ectopic intrauterine devices (IUDs) in the anterior wall of urinary bladder. A 52-year-old woman was diagnosed an ectopic IUD in the anterior wall of urinary bladder via abdominal ultrasound and computed tomography examination. The IUD and oval calculus were successfully and completely removed using a laparoscope. The choice of surgical method is determined by comprehensively considering the position of the IUD in the urinary bladder, the size of the calculus, and the situation of intravesical inflammation.

INTRODUCTION

An intrauterine device (IUD) is a contraceptive device placed in the uterine cavity and is a commonly used contraceptive method for women of childbearing age[1,2]. An IUD is usually made of materials such as stainless steel, plastic, and silicone/rubber[3]. According to data from the World Health Organization, two-thirds of women worldwide wear IUDs in China[1]. However, the shape and position of an IUD may change due to the placement time, intrauterine pressure and other factors, resulting in complications[4]. Ectopic IUDs are among the most serious complications. Ectopic IUDs can lead to contraceptive failure, vaginal bleeding, lower abdominal pain and organ damage. According to statistics, the incidence of IUD displacement is approximately 1/2500-1/3000[5]. Ectopic IUDs are common in the myometrium and periuterine organs, such as the rectum, sigmoid colon, uterine appendage, greater omentum, and appendix[6]. There are few reports of ectopic IUDs in the urinary bladder, especially in the anterior wall. Intravesical translocation of an IUD may present as suprapubic pain or discomfort, dysuria, recurrent urinary tract infections, or calculus formation. In this paper, we present a case in which the IUD was ectopic to the anterior wall of the bladder with bladder calculus.

CASE PRESENTATION

Chief complaints

A 52-year-old woman was hospitalized for a urinary bladder foreign body found via abdominal ultrasound and computed tomography (CT) examination in the outpatient department of our hospital. The patient was referred for urological treatment.

History of present illness

The patient has a mild tenderness in the lower abdomen, accompanied by frequent urination, urgency and dysuria.

History of past illness

The patient had a 2-year history of recurrent abdominal distension and lower abdominal pain, accompanied by frequent urination, urgency, dysuria and other discomfort. In the past 2 years, the patient has been diagnosed with urinary tract infection many times in the outpatient department and treated with quinolones and cephalosporins, but the treatment efficacy is poor. The patient said that she had an implanted IUD in the uterine cavity 20 years prior.

Personal and family history

The patient had no previous or family history of similar illnesses.

Physical examination

Physical examination after admission revealed no percussion pain in the bilateral renal areas, no tenderness in the ureter areas, and mild tenderness in the lower abdomen.

Laboratory examinations

C-reactive protein and blood cell analysis revealed no abnormalities. Urine tests revealed the following results: blood +1 (normal range Neg), leukocyte esterase +1 (normal range Neg), specific gravity > 1.030 (normal range 1.010-1.025), red blood cell = 50/μL (normal range 0.00-17.00/μL), and white blood cell = 50/μL (normal range 0.00-28.00/μL).

Imaging examinations

Bladder ultrasound and pelvic CT revealed a ring-shaped foreign body in the anterior wall of urinary bladder (Figure 1), an ectopic IUD be considered.

Figure 1 Preoperative imaging examinations. A: Bladder ultrasound showed abnormal echo in the urinary bladder; B: Abdominal computed tomography showed that there were annular dense shadow and high-density shadow in the anterior wall of urinary bladder.

FINAL DIAGNOSIS

Considering the patient’s history and laboratory and imaging findings, the patient was diagnosed with ectopic IUD in urinary bladder.

TREATMENT

The surgery is carried out under a general anesthesia. Laparoscopic surgery was performed after the intestinal tract and fallopian tube adhesions were separated, an annular IUD embedded into the muscularis was found in the right anterior wall of urinary bladder, and an oval calculus with a diameter of approximately 2 cm was attached to the surface of the bladder cavity (Figure 2A). The IUD and calculus were successfully and completely removed, and the bladder wall was sutured to the full thickness (Figure 2B).

Figure 2 Laparoscope surgery images of an ectopic intrauterine device. A: Under laparoscopy, an annular intrauterine device embedded into the muscularis was found in the right anterior wall of the bladder, and an oval calculus with a diameter of approximately 2 cm was attached to the surface of the bladder cavity; B: The intrauterine device and calculus were removed during laparoscopic surgery.

OUTCOME AND FOLLOW-UP

A urinary indwelling catheter was used after the operation, and antibiotics were administered to prevent infection. The patient was discharged with a urinary catheter after 3 d of operation. The patient returned to the hospital 2 wk later for removal of the urinary catheter. The patient urinated normally without vaginal bleeding, abdominal pain or other discomfort.

DISCUSSION

There are many reasons for ectopic IUD: (1) Due to an unskilled operator, the position and size of the uterus are not accurately judged, and the direction of the probe or placer into the uterine cavity is wrong; alternatively, the operator is too rough and fails to pay attention when encountering resistance at the bending region and the probe is forced through, resulting in uterine wall damage, perforation and ectopic IUD[7]; (2) When placing an IUD on a woman with a scarred uterus, the scar tissue is easily damaged due to the lack of elasticity of connective tissue at the incision in the uterus, and carelessness can cause ectopic IUD. In addition, when women enter the perimenopausal period, the uterine cavity begins to shrink, which can cause the IUD to deform and embed into the myometrium; the longer the menopausal period is, the more serious the uterine atrophy and the greater the incidence of IUD incarceration[7]; and (3) The size and shape of the IUD do not match the shape of the uterine cavity.

The incidence of IUD penetrating the uterine wall is less than 1/1000, and there are few reports indicating IUD in the urinary bladder, especially in the anterior wall[8]. The location of the IUD in the urinary bladder may be associated with the chronic effect of the IUD in the uterus, which can lead to the formation of an inflammatory reaction, through which the IUD penetrates the uterine wall and contacts the bladder wall to cause inflammatory adhesion, resulting in the erosion and rupture of the bladder wall and the entry of the IUD into the urinary bladder. In addition, this difference may also be related to the intense exercise of patients after IUD implantation. The ectopic IUD in this patient was caused by chronic inflammation, and the IUD was located in the anterior wall of the urinary bladder. Calculus had formed on the surface due to chronic inflammation.

The diagnosis of ectopic IUD is relatively simple. Transvaginal and abdominal ultrasound is an effective method for identifying ectopic IUD[9]. Abdominal X-ray imaging is very effective for diagnosing metal IUDs, but it is unable to locate the IUD. Multislice spiral CT and nuclear magnetic resonance imaging have obvious advantages in terms of localization and imaging and can help surgeons more clearly determine the location of the IUD.

When it is confirmed that the IUD is located in the urinary bladder, surgery should be performed as soon as possible. At present, there are cystoscopy, hysteroscopy combined with cystoscopy, laparoscopy and open surgery. The choice of surgical method is determined by comprehensively considering the depth of the IUD in the bladder muscle layer, the situation of complicated calculus, the situation of intravesical inflammation and medical technology and equipment. If the IUD is completely or mostly in the urinary bladder, it can be removed by cystoscopy[10]. If part of the IUD is intraperitoneal, it may be removed by laparoscopy, or laparoscopy combined with cystoscopy. However, if these methods are difficult to remove, open surgery is required[10]. In the present case, part of the IUD is located outside the bladder and adheres to the surrounding tissues, the IUD and calculus may not be completely removed by cystoscopy, and the open surgery is more traumatic, so we choose laparoscopic surgery.

CONCLUSION

In conclusion, we reported a case of an ectopic IUD in the anterior wall of urinary bladder that was documented 20 years after IUD insertion. Abdominal ultrasound and CT are effective methods for detecting ectopic IUDs. The IUD is located in the urinary bladder and requires early surgical treatment. At present, there are cystoscopy, hysteroscopy combined with cystoscopy, laparoscopy and open surgery. The choice of surgical method is determined by comprehensively considering the position of the IUD in the urinary bladder, the size of the calculus, and the situation of intravesical inflammation.