Perforation of the bladder by the intrauterine device.

Abstract

Probably because of its rarity, the IUD complication of bladder perforation has seldom been diagnosed prior to intervention. This article presents in tabular form data on 8 cases of bladder perforation by IUDs in an effort to develop appropriate methods of preoperative diagnosis. Several types of bladder perforation were found in the 8 cases. The main symptom was recurrent and persistent cystitis which usually responded only temporarily to therapy. Symptoms included dysuria, burning on urination, frequency, nocturia, occasional hematuria, lower abdominal and suprapubic pain, and bladder pressure. Objective evidence was provided by microscopic pyuria and hematuria, as well as positive urine cultures. In most cases, symptoms appeared soon after insertion or within a few months. Attacks of cystitis starting shortly after insertion of the IUD and continuing repetitively should arouse suspicion of bladder perforation, and concomitant absence of the IUD string or unanticipated pregnancy should heighten the suspicion. Preliminary investigation prior to cystoscopy is preferrable beginning with a plain X-ray film in anteroposterior (AP) and lateral projections. If a bladder calculus has not formed or is insufficiently radiopaque, the AP film can be misleading unless a lateral film is also taken. Although it was used in only 2 cases, sonography will probably prove increasingly valuable in the diagnosis of bladder perforations by IUDs. If sonography does not demonstrate the intravesical IUD, opacification of the bladder by intravenous pyelography or retrograde cystography, using AP and lateral films, may show it. Hysterography may be helpful when sonography or intravenous pyelography or retrograde cystography give a hint of concomitant partial uterine location of the IUD. Cystography after preliminary tests can help in planning the optimal approach for removing the IUD. In the 8 cases the free-floating IUD was removed by cystoscopy in 3 cases, the adherent IUD by suprapubic cystotomy in 4 cases, and by vaginal cystotomy in 1 case. In general, suprapubic cystotomy is the procedure of choice for removing an IUD perforating into and adherent to the bladder wall.