urethral catheterization is one of the most commonly performed procedures in healthcare settings worldwide , with more than 5 million urinary catheterization in the united states in the year 2000 alone ( 1 ) . adding to this , it is usually safe and relatively easy if performed by well - trained healthcare personnel . although it is considered as simple and safe procedure , however , clinicians including urologists can encounter significant difficulties and traumatic catheterization is sometimes possible . catheter related complications , such as infection , bleeding , injury to the urethra or bladder , or catheter malfunction can ensue ( 2 ) . moreover , insertion of the urethral catheter can be exceedingly difficult particularly in patients with underlying problems such as existing urethral strictures and elevated bladder neck due to severely enlarged prostate . likewise , placement of the urethral catheter in neuropathic bladder patients can also be challenging due to periodic catheterization leading to more traumatized urethra . herein , we report a first case of intraperitoneally placed urethral catheter via verumontanum , which was presented as intraperitoneal bladder perforation , in a chronically malnourished bed - ridden elderly man . a 82-yr old male was admitted to our department for sudden onset acute abdominal pain . he also has a significant history of urinary incontinence which became progressively worse and an insertion of foley catheter was recommended at a private healthcare institute . briefly following this , a 14 fr foley catheter was placed after a second attempt by a non - trained orderly at the private healthcare institute . two days later , slightly blood tinged urine was observed on his urinary drainage bag . he had a past medical history of hypertension for 10 yr , brain surgery for intracranial hemorrhage 5 yr ago and total left hip arthroplasty 10 yr ago . his body temperature was 36.7. there was mildly left - shifted leukocytosis ( wbc : 9,300/l ) on complete blood count but it was within upper normal limit . although the bladder integrity was checked with bladder irrigation and aspiration , we observed a significant discrepancy between input and output fluid volumes . the retrograde cystography showed extravasation of the contrast material into the peritoneal cavity and the foley catheter balloon which was placed in peritoneal cavity ( fig . subsequently , emergency laparatomy was performed . however , there was no bladder perforation noted and the tip of the foley catheter was noticed at the rectovesical pouch . given the location of the foley catheter , we considered the possibility of false passage of the urethral catheter and subsequently removed the entire catheter . to further examine the extent of urethral injury , on - table , intraoperative urethrocystoscopy was performed . the urethrocystoscopical examination revealed a tunnel - like false passage extending from the verumontanum into the rectovesical pouch between the posterior wall of the bladder and the anterior wall of the rectum . furthermore , a small hole into the peritoneum was also identified during cystoscopy ( fig . 1b ) . following the identification of the extent of the urethral injury , a 16 fr open ended nephrostomy tube was indwelled and safely secured into the bladder under guidance of amplatz guide wire after full cystoscopic examination . in addition , a 16 fr cystostomy tube was placed into the bladder suprapubically to ensure adequate urinary drainage . then , the perforated rectovesical pouch was repaired transperitoneally with simple continuous suture and a closed suction drain was left into the peritoneum . the patient was discharged to the private care institution with only suprapubic cystostomy tube 7 days after the surgery . the two most common complications related to foley catheters , particularly in males , are anterior urethral injuries which can lead to long - term sequelae , such as urethral stricture , and retention of the catheter balloon in the urethra ( 3 ) . serious complications , indeed such as bladder perforation and/or peritonitis and rectovesical fistula have been previously reported ( 4 - 6 ) . however , to date , urethral foley catheter misplacement into the peritoneum without bladder injury has not been yet reported in the literature . this present patient was a chronically debilitated , malnourished and bed - ridden state for a relatively long period of time of 5 yr following brain surgery . therefore , we can suggest that his body connective tissues could be loosened and weakened as a result . at the time of surgery , cystoscopic findings revealed highly elevated bladder neck and destructed verumontanum area with a tunneling to the peritoneal cavity . however , there was no structural abnormality with exception of moderate trabeculation on the bladder . although it is difficult to fully understand the mechanism of this injury , we can hypothesize that the sheer force of the foley catheter allowed penetration into ejaculatory duct and peritoneum . structurally , the existence of the highly elevated bladder neck as well as the widely opened verumontanum can partly be contributing to such an injury . another challenging aspect in this patient 's presentation was the partial drainage of urine via the foley catheter , but we presumed that this was possible because the leaked urine was back flowed around the catheter . this case illustrates that misplacement of foley catheter via verumontanum through peritoneal cavity without bladder perforation in a chronically debilitated man might be possible . it also shows that foley catheterization , though it is simple and usually safe procedure , it can potentially cause serious problem like this present case , if performed by non- or less - trained healthcare providers . therefore , we would like to emphasize that the best way to avoid traumatic catheterization would be adherence to the basic principles of catheterization . firstly , the procedure has to be performed by physician or very well - trained healthcare provider . secondly , one must abandon the procedure and an urgent urological consultation should be immediately sought whenever any urethral resistance or bleeding during urethral catheterization encountered . finally , we should pay particular attention to confirm the location of the foley catheter and/or balloon before inflation by the aspiration of urine . adding to this , clinicians , particularly urologist should increase awareness of the potential catheter related complications among other healthcare providers and perhaps encourage to adopting a proper technique of catheterization as well as provide adequate training and supervision of those healthcare and/or non - healthcare personnel who intent to perform this procedure in the future .