Previous medical history revealed recurrent urinary tract infections, treated with antibiotic therapy. Furthermore she was treated for hypertension by -blocker therapy (Metoprolol) and cardiac glycoside (Lanoxin). For years, she had been using incontinence pads because of urinary incontinence. For the past 7 years she progressively developed chronic kidney disease (serum creatinine: 193 µmol/l).

She withdrew from medical follow-up when she moved to a nursing home after suffering from a cerebrovascular accident in 2005.

Haemodynamics were stable (mean arterial pressure of 103 mm Hg and a regular pulse of 66 beats per minute).

Haemodialysis was started.

Flexible cystoscopy revealed a bladder full of debris and a large calculus penetrating the posterior bladder wall just above the trigone. Ultrasound examination showed bilateral slender calyceal systems and small kidneys (longitudinal size of 8 cm) with a thin homogenous cortex (1 cm).

Urine culture demonstrated an Escherichia coli infection.

The intravesical stone fragment seemed to be fixated in the bladder wall and could not be removed (figure 2).

Although the contraceptive device burdens a low complication rate, it may cause serious early and late complications. Users are at risk of septic abortion, ectopic pregnancy and pelvic inflammatory disease, even in case of antibiotic prophylaxis at time of insertion.^{3 4}

An uncommon, but severe complication of the IUD is uterus perforation; either partial, in which the device may be embedded in the uterine wall and mostly not diagnosed at time of insertion, or complete, perforating the myometrium and serosa.⁶ In a reviewed cohort of 16, 159 IUD users, a perforation incidence of 1.6 per 1000 insertions was reported, both partial and complete.³

In case of complete perforation of the uterine wall, the device might migrate to the peritoneal cavity and can ultimately intrude neighbouring viscera. In 53 of the 356 reviewed cases of uterine perforation by Zakin et al⁸, migration to adjacent organs has been reported, predominantly gastro-intestinal migration (41 cases) and perforation of the urinary bladder (6 cases). Kassab et al⁵ reviewed 165 cases of migration beyond the peritoneal cavity, including the omentum (45 cases), rectosigmoid (44), peritoneum (41), appendix (8), small bowel (2), adnexa and iliac vein (1). In 23 cases the bladder was involved.

Unlike in other organs, urinary bladder perforation may initiate stone formation, since an intravesical foreign body may cause calcium precipitation and may serve as a focus of crystallisation. Partial or total IUD-encrustation is reported in 18 of the 41 cases of urinary bladder perforation reviewed by Özçelik et al.⁷

Apart from calculus formation, irritative voiding symptoms, recurrent urinary tract infections, suprapubic abdominal pain and haematuria may be present in case of bladder involvement.^{9 10}

Also (hydro) ureteronephrosis and pyelonephritis have been reported.¹¹ In our case, urinary infection impaired renal function severely, contributing to the end-stage kidney disease.

Perforation incidence seems related to the experience of the inserting (para)medical personnel, the size and uterus configuration (anteversion or retroversion), uterus anomalities and cervical anatomy.^{10 12} Some authors advocate that IUD insertion during the puerperium and in lactating may facilitate perforation, probably due to involution of the uterus, (small sized and thin walled) and because of strong uterus contractions (secondary to oxytocin and prolactin production).¹¹ Postpartum low oestrogen levels make the uterus more fragile and vulnerable for perforation. Another possible risk factor is a reduced pain sensation during breastfeeding due to increased levels of β-endorphins, so uterine perforation may remain unnoticed.⁹

In the present case, a ‘Lippes loop’, the first small polyethylene IUD with a monofilament tail, was retrieved. While in most cases the perforation is diagnosed within 1 year after insertion, in our case, the device was recovered 39 years after insertion, to our knowledge the longest period reported.⁹ Ever since the Lippes Loop, a wide variety of IUD models has been found in adjacent organs, mostly copper containing.¹³ Even the modern hormone-releasing IUDs have been extracted from the urinary bladder.¹⁴

In case of a missing IUD, cystoscopic examination should exclude bladder involvement. Gruber et al¹⁵ presented an algorithm in the management of a missing IUD before localization of the device by cystoscopy. They propagate the less invasive simple pelvic x-ray or ultrasonography to confirm the IUDs location, or secondary hysterosalphingography to clarify the relation between the uterus and IUDs location.

Missing IUDs may be assumed to be expelled, for example during regular follow-up, when at vaginal examination the tail or strings of an IUD are missing, or when a woman gets pregnant. Careful examination to verify IUD expulsion is advised in such cases. An illustrating example is the report of a woman in whom even two missing extra-uterine IUDs were detected.¹⁵

Removal of dislocated IUDs is recommended by the World Health Organization, because of the formation of adhesions, medicolegal and psychological indications.¹⁶ Laparoscopic retrieval in case of intraperitoneal localisation is a minimal invasive option. Transurethral retrieval and eventually stone removal is ideal in intravesical located devices. In case of significant stone load, an open procedure may be more favourable. Other defects, like vesico-vaginal fistulas could also be managed during this procedure.