Inadvertent antegrade urethral placement of a suprapubic catheter

Presentation A 55-year-old male patient with neuropathic bladder secondary to multiple sclerosis (MS) presented to the Emergency Department (ED) with abdominal pain and no output from his suprapubic catheter (SPC) that was changed 24 hours previously. 

Diagnosis On examination, the SPC-tip was clearly visible at the external urethral meatus. 

Treatment The patient was managed by gently deflating the anchoring balloon, exchanging the SPC and a period of observation to ensure adequate catheter drainage.

Conclusion Important learning points from this case are to observe urine draining after routine SPC change and to examine the genitalia when a misplaced SPC is suspected.