Vesicouterine fistula with vesical calculi secondary to IUD migration: a case report.

The case report details the medical history and treatment of a 31-year-old woman who experienced complications from a “T-shaped” intrauterine device (IUD) implanted 10 years earlier.The patient has a history of one pregnancy and one live birth.Her medical history included a cesarean Sect. 12 years prior, a suction curettage for induced abortion 11 years ago. She had no history of pelvic inflammatory disease, endometriosis, or prior pelvic surgery beyond the aforementioned procedures. The patient reported no complications during her cesarean delivery or abortion.The patient’s prior uterine scarring from a cesarean section, which increases adhesion formation and weakens the uterovesical interface, along with repeated intrauterine instrumentation (abortion and IUD insertion) that may cause microperforations or inflammation, are all significant risk factors for the development of vesicouterine fistula.Despite having a normal menstrual cycle and no apparent symptoms like periodic hematuria or vaginal urination, the patient had not undergone regular gynecological examinations. Two weeks before admission, she experienced lower abdominal pain and underwent a hysteroscopic examination at a lower-level hospital, no contraceptive device found in the uterus. Later, a foreign body was detected in the bladder by ultrasound, and then she was transferred to our hospital for further treatment. After admission, a CTU (Fig.  1 ) examination revealed that the bladder wall was swollen and thick, a nodular shadow visible in the left posterior area, with a maximum cross-sectional area of approximately 2.9 cm*1.8 cm. A T-shaped dense shadow was connected to it, with a left to right diameter of approximately 2.8 cm and an upper to lower diameter of approximately 3.4 cm. No extravasation of contrast agent was observed during excretion. After admission, the patient was placed with an indwelling catheter for dysuria, showing unobstructed drainage. However, visible hematuria was observed two days later, lasting for 5 days, without any other discomfort. The patient stated that those 5 days should be in her regular menstrual period, but no menstrual blood found in the vagina. We did not perform any special treatment, and 5 days later, the patient’s hematuria stopped. Combined with the clinical characteristics, the 5-day hematuria of the patient is highly likely caused by menstrual blood influx. We performed a cystoscopy on the patient under general anesthesia and found that the T-shaped contraceptive device was completely free in the bladder, with vesical calculi (max diameter about 3 cm) formed on one head, with a maximum diameter of about 3 cm (Fig.  2b ). A fistula (Fig.  2a ) was visible above the trigonum vesicae, with cicatrices formed around it. It was about 1 cm in diameter, and about 3 cm and 2 cm away from the bilateral ureteral openings, respectively. We advanced the rigid ureteroscope directly into the uterine through the fistula (Fig.  2d ), which was located approximately 1 cm from the anterior wall of the uterine near the cervix. It was clearly diagnosed as a vesicouterine fistula. The surgery steps were as follows: Holmium laser was used to crush the vesical calculi through the urethra and flush them out, and then performed a laparoscopic vesicouterine resection + uterine and bladder repair, and IUD removal (Fig.  3c ). The fistula (Fig.  3d ) and surrounding scar tissue were completely dissociated and removed. Fig. 1 Preoperative CT examination Preoperative CT examination Fig. 2 Intraoperative situations during cystoscopy a :Trigonum vesicae fistula b : Vesical calculi enveloping one end of the IUD - this image displays the bladder stones that have formed around one end of the intrauterine device (IUD). c : IUD end and bladder fistula d : Cystoscopy of vesicouterine fistula - an image illustrating the vesicouterine fistula, providing a visual understanding of the connection between the bladder and the uterus Intraoperative situations during cystoscopy a :Trigonum vesicae fistula b : Vesical calculi enveloping one end of the IUD - this image displays the bladder stones that have formed around one end of the intrauterine device (IUD). c : IUD end and bladder fistula d : Cystoscopy of vesicouterine fistula - an image illustrating the vesicouterine fistula, providing a visual understanding of the connection between the bladder and the uterus Fig. 3 Intraoperative situations during laparoscopic surgery a : Laparoscopic indications - this figure includes indications with arrows: a red arrow pointing to the bladder wall, a blue arrow to the bladder fistula, and a yellow arrow to the uterus, aiding in identifying these key structures. b : A laparoscopic view showing the uterus fistula, with a red arrow highlighting its location. c : IUD removal d : Completely removed fistula Intraoperative situations during laparoscopic surgery a : Laparoscopic indications - this figure includes indications with arrows: a red arrow pointing to the bladder wall, a blue arrow to the bladder fistula, and a yellow arrow to the uterus, aiding in identifying these key structures. b : A laparoscopic view showing the uterus fistula, with a red arrow highlighting its location. c : IUD removal d : Completely removed fistula A four-port laparoscopic surgical approach was utilized. Initially, at the relatively normal tissue plane of the vesicouterine junction, the serosal layer was carefully incised using an ultrasonic scalpel to enter the potential space, followed by progressive sharp dissection. Dissection was performed along the loose adhesions from superficial to deep layers using the ultrasonic scalpel. The bladder was exposed, and the posterior bladder wall was incised with the ultrasonic scalpel. The fistula was identified from within the bladder, and approximately 0.5–1 cm of scar tissue surrounding the bladder fistula opening was excised. The fistula tract was dissected, and atraumatic graspers were used to explore and stabilize the fistula. The ultrasonic scalpel was then employed to completely excise the surrounding scar tissue along the fistula tract from superior to inferior. Dissection continued toward the uterus, and 0.5–1 cm of scar tissue around the uterine fistula opening was resected, ensuring complete removal of the fistula tract. The “T-shaped” intrauterine device (IUD) was extracted from the bladder. A 3 − 0 absorbable suture was used to perform continuous suturing of the bladder mucosal layer, followed by the muscular layer. A small amount of normal saline was injected into the bladder to observe the suture site and check for leakage. The uterine muscular layer was closed with a 2 − 0 absorbable suture using a continuous technique. Finally, the serosal layer was covered with continuous sutures to minimize the risk of postoperative adhesions, and an abdominal plasma drainage tube and a urinary catheter were retained, resulting in approximately 100 ml of intraoperative bleeding. The surgery lasted for 140 min and was successfully completed. The pathological examination of the fistula revealed chronic inflammation with focal fibrosis. Preoperatively, the patient underwent two urine culture tests, both of which showed no bacterial growth. Postoperatively, third-generation cephalosporin antibiotics were administered for prophylactic infection treatment three days.We removed the plasma drainage tube and the urinary tube at 5 days and 2 weeks after the surgery, respectively. Regular follow-up was conducted until 12 months after the surgery. Retrograde cystoscopy at 3 months: No residual fistula, calculi, or inflammation was observed.The uterine cavity appeared normal, with no adhesions or signs of perforation.Abdominal CT at 9 months: Complete resolution of the fistula and no recurrence of calculi.The patient remained asymptomatic with regular menstruation and no urinary complaints at 12-month follow-up.

Intrauterine device (IUD) is a common contraceptive method, generally using “T” and “O” types. Uterine perforation caused by the IUD can be limited to the uterine cavity and myometrium; a few causes rupture of the peritoneal cavity, and very few penetrate the surrounding organs. In general, IUD displacement can lead to related gynecological symptoms, such as prolonged menstrual period, significant increase in menstrual bleeding, and unexpected pregnancy. There are many reported cases of vesical calculi caused by IUD displacement [ 5 , 6 ], and the treatment methods include transurethral cystoscopic vesical calculi lithotripsy combined with IUD removal, or cystotomy combined with IUD removal. Vesicouterine fistula is a relatively rare clinical disease, and cases of vesicouterine fistula combined with vesical calculi caused by IUD displacement are even less reported. Vesicouterine fistula can be divided into three types. Type I clinical manifestations include periodic hematuria, no vaginal bleeding during menstruation, and controllable urine without vaginal urination, namely typical Youssef’s syndrome. Type II symptoms include periodic hematuria, no vaginal bleeding during menstruation, and vaginal urination. Type III is characterized by normal menstruation, no periodic hematuria, and may or may not be accompanied by vaginal urination [ 7 ]. Type I is the most common, accounting for about 90% [ 8 ], while Type III is the least common, especially in patients without vaginal urination, where symptoms are very insidious. Cystoscopy and hysterography are the gold standards for diagnosing vesicouterine fistula [ 3 ]. There is literature reporting that MRI is highly sensitive in diagnosing vesicouterine fistula [ 8 ]. Vesicouterine fistula may cause complications such as infection, bacteremia, infertility, and miscarriage. Once discovered, it must be treated by conservative or surgical methods. It has been reported that the overall effective rate of conservative treatments is less than 5%, and the vast majority of patients with vesicouterine fistula need surgical treatment to repair the fistula [ 9 , 10 ]. Repair surgery can be transvaginal, or transabdominal, and conventional or robotic laparoscopy can be adopted for repair. Laparoscopic repair was chosen for its minimally invasive advantages, including enhanced visualization, reduced postoperative pain, and faster recovery. The technique allowed precise dissection of dense adhesions and fistula excision while preserving ureteral integrity. Compared to transvaginal or open approaches, laparoscopy minimizes adhesion formation, critical for preserving fertility—a key consideration for this young patient. The patient involved in this case is a young woman who has been indwelling an intrauterine device for a long time. Although she had periodic hematuria before the surgery, no typical symptoms such as periodic hematuria and vaginal urination was found throughout the entire medical history. It is a rare type III vesicouterine fistula, and preoperative imaging examination did not show any signs of contrast agent leakage. Therefore, the characteristics of this case are extremely atypical, making it difficult to accurately diagnose before the surgery. Based on the patient’s menstrual cycle, as well as the location of the vesicouterine fistula and the manifestations of uterine congestion and edema discovered during the surgery, we can infer that the hematuria of the patient for 5 consecutive days before surgery was caused by the inflow of menstrual blood.The patient had no symptoms of periodic hematuria or vaginal urinary incontinence for many years. Initially, the T-shaped IUD might have acted as a mechanical barrier, partially obstructing the uterovesical fistula and preventing the backflow of menstrual blood into the bladder. Even after the IUD had completely migrated into the bladder, the absence of related symptoms could be attributed to factors such as the fistula’s location, direction, size, and high bladder pressure. It is precisely because after admission, we left a urinary catheter, causing the bladder to be empty and the uterine pressure to be greater than the bladder pressure. In addition, she was in the menstrual period, so menstrual blood flows from the uterus into the bladder, exhibiting the characteristic of periodic hematuria. The resection of the vesicouterine fistula is a challenging procedure. The key to successful surgery lies in the complete removal of the fistula and the surrounding scar tissue. A common approach is to open the peritoneum at the concave part between the bladder and uterus, separate the bladder and uterus, and locate the fistula. However, severe adhesions in the surrounding area made the surgery quite challenging. We decided to incise the bladder near the fistula, identify the fistula from within the bladder, completely separate the fistula along its tract, and fully excise both the bladder and uterine ends of the fistula. Throughout the surgery, utmost care was taken to avoid any damage to the ureteral openings. Finally, absorbable sutures were utilized to meticulously close the bladder mucosa, muscular layer, and uterine wall layer by layer. Post-surgery, abdominal drainage and urinary catheters were retained for monitoring and recovery purposes. The patient’s postoperative outcomes demonstrated significant clinical improvement. Follow-up evaluations restored menstrual regularity, all of which directly enhanced her quality of life. Symptom relief, including resolution of lower abdominal pain and transient hematuria, alleviated physical discomfort and psychological distress associated with the condition. Regarding fertility potential, the laparoscopic approach prioritized minimizing adhesions and preserving anatomical integrity, critical for a young patient of reproductive age. Successful closure of the uterine defect and meticulous repair of the bladder and uterus likely reduced risks of future obstetric complications, such as miscarriage or preterm labor, though long-term fertility outcomes require further monitoring. This case exhibits distinct clinical and diagnostic characteristics compared to previously reported vesicouterine fistula (VUF) cases secondary to intrauterine device (IUD) migration. Unlike typical VUF presentations dominated by Youssef’s syndrome, our patient lacked hallmark symptoms, resulting in delayed diagnosis.Most literature describes Type I VUF (90% of cases) whereas this represents a rare Type III VUF with insidious onset, normal menstruation, and transient hematuria coinciding with menses—features that obscured initial clinical suspicion. The coexistence of vesical calculi encasing a migrated IUD further distinguishes this case. While bladder stones secondary to IUD migration have been documented, their concurrent presence with a VUF is exceptionally rare. This combination necessitated a dual surgical approach—holmium laser lithotripsy and laparoscopic fistula repair—highlighting the complexity of managing multifocal complications. In summary, this case emphasizes the importance of heightened suspicion for VUF in patients with a history of IUD migration, even without classic symptoms. Its uniqueness lies in the triad of diagnostic obscurity, concurrent vesical calculi, and successful fertility-sparing laparoscopic management—a valuable addition to the limited literature on atypical VUF presentations.

Intrauterine device (IUD) is a common contraceptive method used by about 14% of women [ 1 ], known for its minimal systemic interference, safety, effectiveness, and ease of use. In a few cases, however, complications may still occur, endangering the physical and mental health of patients. One such severe complication is uterine perforation caused by IUD displacement, which can lead to erosion into the urinary and digestive tracts, manifesting in systemic symptoms. Vesicouterine fistula accounts for a relatively low proportion, about 7–9% [ 2 ], of urogenital fistula diseases, mostly occurring after cesarean section, accounting for about 83–93% of vesicouterine fistula cases [ 3 ]. The typical clinical manifestations of vesicouterine fistula include a triad of periodic hematuria, no vaginal bleeding during menstruation, and controllable urine, known as Youssef’s syndrome [ 4 ].

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