A Foley folly: Unintended proximal urethral catheterization and balloon inflation causing urethral injury during suprapubic cystostomy exchange

Urinary catheter dysfunction is a common emergency department presentation for patients with neurogenic bladders. Many of these patients have cystostomies requiring routine suprapubic catheter exchange. On complication of outpatient catheter replacement, patients are often sent to the emergency department (ED). We describe the case of an 81-year-old male presenting with painless hematuria and blood from the urinary meatus after undergoing routine cystostomy exchange. During Foley replacement, the suprapubic catheter entered the proximal urethra and the balloon was inflated while in the prostatic urethra, leading to urethral injury and cystic clot formation. Emergency physicians should be aware of this rare complication of suprapubic catheter placement.