Maturitas 60 (2008) 180–181 Available online at www.sciencedirect.com Case report Knotted urethral catheter in an 80-year-old woman: Prevention and management of this unusual complication M.C. Sighinolfi * , S. De Stefani, S. Micali, A. Mofferdin, A. Beato, N. Ferrari, G. Bianchi Department of Urology, University of Modena and Reggio Emilia, Italy Received 29 January 2008; accepted 6 February 2008 Abstract Intravesical catheter knotting represents a rare event, especially described in paediatric literature. We report a case of a catheter knot, occurring in an 80-year-old woman, managed by means of sustained traction. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Urethral catheter; Complication; Knot 1. Introduction Urethral catheterization is one of the most fre- quently performed practical procedures in urology. Catethers can be inserted due to various reasons, rang- ing from long-term catheterization in case of prostatic hypertrophy in the elderly patients, to urological diag- nostic procedures, as cystometry or cystouretrography. Complications of such practice are rare events, but have been described especially in pediatric series [1]. In this paper, knot formation in the double lumen urethral catheter of an old woman has been reported. * Corresponding author. Tel.: +39 059 4224766. E-mail address: sighinolfic@yahoo.com (M.C. Sighinolfi). 2. Clinical case A woman aged 80 years was admitted to our department for failure to remove the bladder catheter. The patient was bearing the catheter since several years before, due to senilis dementia that avoided any kind of patient’s self-government. During the routinely catheter substitution, catheter balloon deflation turned out to be unsuccessful and domiciliary nurses cut the external end to obtain catheter removal. The procedure was ineffective, and the patient was referred to the hos- pital. Expecting a trouble with the balloon, we tried to incise it with a guide wire straight in the balloon lumen, but without any outcome. Only after a sustained traction, without anaesthesia, the catheter came out, revealing a knot at its proximal end (Fig. 1). A new catheter was easily inserted, and a subsequent ultra- 0378-5122/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.maturitas.2008.02.013