ventriculoperitoneal ( vp ) shunting for hydrocephalus is a common neurosurgical procedure in our daily practice . migration of distal part of vp shunt into the adjacent organs including bowel tract , thoracic cavity , heart , scrotum , umbilicus , abdominal wall , and urinary bladder is reported . a case of repeated shunt migration in different organs this is the first case of bowel perforation with transanal extrusion continued with bladder migration and urethral extrusion of peritoneal shunt . we report our case of a child with these unusual complications ; treatment was done by a team involving neurosurgeons and urologists . a 4-year - old boy was admitted to the hospital because of abdominal discomfort . on further examination the first operation was undertaken when he was 2 months old because of his congenital hydrocephalus . the patient went back to the hospital when he was 1 year old because of severe headache . computed tomography ( ct ) scan confirmed a large right porencephaly . his abdominal x - ray revealed that the extruded shunt was the right peritoneal catheter [ figure 2 ] . the result was showing 200 cells found with protein 100 mg / dl , glucose 13 mg / dl , and the culture showed micrococcus sp . urological procedure was performed endoscopically through the urethra to explore the site of migration and potential of leakage . it was found that the shunt was penetrated through the bladder wall just above the trigonal area [ figure 3 ] . we decided to treat conservatively by inserting an urethral catheter to keep the bladder decompressed for optimal healing process . extruded shunt was exposed through the external urethral orificium abdominal x - ray shows the extruded ventriculoperitoneal shunt cathether through the urethral orificium during endoscopic urological surgery , migration site just above the triogonal area of the urinary bladder was identified ( blue arrow ) thereafter , intraventricular antibiotic was administered according to the culture results . one month later , culture of csf was performed and it showed a sterile result . bowel perforation was present in 0.1%0.7% of cases in which colon was the most involved organ , and the most common site of extrusion is anus ( 68.9% ) , followed by scrotum ( 22% ) , umbilicus ( 6.9% ) , and vagina ( 3.2% ) . a case of urinary bladder migration as well as urethral extrusion of vp shunt is extremely rare . there have been various theories proposed such as bioreactivity , local inflammation , infection , and surgical error . the location of the bladder makes it highly unlikely site of perforation , as the catheter must pass through the peritoneum into the extraperitoneal space and subsequently perforate the bladder . in this present case , the first migration of the catheter was into the anus , and this is considered as a frequent event of migration . the second migration into the bladder is a rare case . symptom was only abdominal discomfort and it became obvious after the expose through the urethral orifice . repeated case of shunt migration is an interesting case regarding the pathophysiology and management of this patient . with the history of prior bowel perforation by shunt catheter , and cultures of specimens indicating an infection fixation of the tip catheter at the specific site of the peritoneum is facilitated and then , continuous erosion and perforation of the peritoneum into the bladder was done . the trigonal area , which comprises less muscle layer , was the site of migration in this case . there are three main procedures of shunt removal : gentle pulling , endoscopic surgery , and major open surgery . as per earlier reports , catheter removal is mostly done by open abdominal surgery , but in author 's opinion , removal of the catheter could be done with a less invasive method . in our case presenting per - urethtraly , the catheter was gently pulled out through the urethral orifice . the surgery was then followed by urological endoscopic exploration through the urethra to view the size and location of the perforation . it is believed that the perforation site seals off due to the presence of a chronic fibrous sheath around the shunt tract and requires no aggressive surgical intervention . we found the pitfall of this case to be the lack of detailed history of the previous operation because the patient underwent the surgery in another hospital . the repeated migrations also give us some thought of another option of shunting , for example , ventriculo - atrial shunt . bladder migration and transurethral extrusion is an extremely rare complication of vp shunt . to our knowledge , this is the ninth case reported . the presence of previous abdominal complication and repeated organ perforation indicates predisposition factors which must be sought and handled before any further treatment .