Exercise-Induced Hematuria as the Main Manifestation of Migration of Intrauterine Contraceptive Device into the Bladder

Intrauterine device (IUD) is a common contraceptive method, due to its cost-effectiveness and low complication rates. Uterine perforation is a possible complication and IUD migration to the bladder is a rare and morbid condition. The present report describes an interesting case in which the urinary manifestations started 13 years after insertion, and the main clinical finding was exercise-induced hematuria. 1. Introduction Intrauterine device (IUD) is a widely used reversible contraceptive method, due to its cost-effectiveness and low complication rates [1]. Serious complications are rare; however migration to adjacent pelvic organs is described [2], including the bladder with stone formation and lower urinary tract symptoms [3]. We describe a case of intravesical IUD migration with urologic manifestations started 13 years after insertion, and the main clinical finding was exercise-induced hematuria. 2. Case Report A previously healthy 39-year-old woman presented with recurrent episodes of gross hematuria after middle distance running (5 to 10？km) that ceased some hours after sports activity, rest, and hydration. Moreover, she reported dysuria, urge to urinate, and suprapubic pain, which also worsened with physical activity. Those symptoms were present for the past 4 months and worsened progressively, becoming more intense in recent weeks. In her previous medical and gynecologic anamnesis, she informed that 13 years ago she underwent implantation of IUD, few weeks after cesarean delivery. After the IUD implant, she complained of suprapubic pain and vaginal bleeding treated with rest and analgesics, with remission of symptoms after approximately 1 month. She was assessed by vaginal ultrasound and informed that IUD was not visualized; twelve years after the implantation of IUD she became pregnant again and had a second cesarean. Gynecologic examination was normal, urinalysis revealed microhematuria, and leukocyturia and urine culture demonstrated the presence of Escherichia coli. She was treated with antibiotics, with remission of symptoms only for 4 weeks. Due to recurrence of the symptoms, she was referred to the urologic department for further evaluation. Ultrasonography demonstrated a 20？mm calculus in the bladder dome (Figure 1) and pelvic helical computed tomography revealed a metallic foreign body partially located intravesically with adjacent calcification (Figure 2). Cystoscopy, performed under anesthesia, confirmed the intravesical IUD (partial), complicated by stone that was grasped by forceps, and extracted completely through the endoscopy