Urethral catheter knotting: an avoidable complication

Urethral catheterisation is a common and safe procedure performed routinely. The small size of the urethra in a child necessitates the use of an infant feeding tube (Size 5 to 8 F) for catheterisation. Knotting within the bladder is a rare complication with significant morbidity often necessitating surgical or endoscopic removal. Insertion of an excessive length of tube contributes to coiling and knotting. We report an instance of knotting of an infant feeding tube in the proximal penile urethra of a 4 year-old male child requiring urethrotomy to remove it. Awareness of the risk and proper technique can reduce this complication.