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This case describes a levonorgestrel intrauterine device (IUD) found to be expelled and retained in the vagina encased in a thick, calcified rind. This case demonstrates that an IUD may be retained as a vaginal foreign body in a patient with decreased mobility and may present with an unconventional appearance. There are several case reports in the literature describing IUDs migrating into the bladder and forming intravesical calculi; there are no case reports describing a similar process of petrification in the uterus or vagina.
The patient is a 12-year-old, medically complex female with global developmental delay, quadriplegic cerebral palsy and epilepsy secondary to congenital cytomegalovirus infection. She had menarche at age 9. A 52 mg levonorgestrel IUD was placed seven months later for menstrual suppression, resulting in significantly lighter menstrual bleeding. After about one year, the patient experienced a return of heavier menstrual bleeding, which persisted for a year prior to presentation. She had a renal ultrasound completed for unrelated complaints that noted a vaginal foreign body, concerning for her IUD. Her exam revealed a rock-like foreign body in the vagina, but no IUD. The object could not be removed in the clinic. She then had an exam under anesthesia (EUA) at which time the foreign body was easily removed. The T-shaped object was encased in a malodorous, hard, brown cast. Breaking the cast revealed the patient's IUD. Another 52 mg levonorgestrel IUD was then successfully placed resulting in excellent menstrual suppression.
In this non-mobile patient, the differential diagnosis included calcified stool or decidual cast, her IUD, or another foreign body. In the office, the foreign body was not clearly identifiable and due to the size could not easily be removed. The EUA demonstrated an encased IUD. This patient's IUD was possibly expelled and then sat in the vagina where layers of surface deposition accumulated and created a stone. We also considered that the IUD was expelled in toto within a decidual cast. The expulsion rate of IUDs in adolescents is reported to be 8.0%. Identifying IUD displacement can be more challenging in patients with developmental disabilities for many reasons. In this case, resumption of heavier menstrual bleeding after initial benefit following IUD placement should have prompted an exam. The IUD was likely rendered ineffective by displacement from the endometrial cavity and possibly by encapsulation within the cast.
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