Case Report: Distal ureteral obstruction decades after presumed intrauterine device removal in a woman with uterus didelphys.

Abstract

Background: An ectopic intrauterine device (IUD) can rarely cause ureteral obstruction and hydroureteronephrosis. Diagnosis may be delayed when a prior removal procedure is believed to have been complete.

Case presentation: A 48-year-old woman presented with a 1-year history of right flank pain and urinary frequency after repeated treatment for presumed urinary tract infection and possible genitourinary tuberculosis without sustained improvement. More than 20 years earlier, an IUD had been inserted before uterus didelphys was recognized. Two to three years later, an unintended pregnancy led to recognition of the duplicated uterine anatomy, induced abortion, and an IUD removal procedure. The original records were unavailable, so device location and intact retrieval at that time could not be verified. Multimodality imaging at the index admission showed severe right hydroureteronephrosis, focal distal ureteral narrowing, and an ectopic metallic IUD outside both uterine cavities; cystoscopy was unremarkable. Open ureteral exploration and reconstruction identified an intact IUD with an attached calculus externally compressing an approximately 1-cm fixed distal ureteral stricture without entering the ureteral lumen. The narrowing persisted after device removal, requiring segmental ureteral resection and anastomosis over a double-J stent. Histopathology of the resected ureter showed chronic inflammatory changes without tuberculous changes. The stent was removed 2 months postoperatively. At 6 months after surgery, computed tomography showed marked decompression of the right collecting system and no residual pelvic metallic device; serum creatinine remained normal.

Conclusion: A history of IUD removal should not be treated as proof of device absence when intact retrieval is undocumented. In otherwise unexplained unilateral ureteral obstruction, a remote IUD history should prompt review of prior device localization and targeted pelvic imaging, particularly when historical records are unavailable or duplicated uterine anatomy complicates localization. A fixed stricture may require reconstruction even after the ectopic device is removed.