Iatrogenic ureteric catheterisation during routine community catheter change resulting in obstructive uropathy, urosepsis and multi-organ failure: a case report

Inadvertent ureteric catheterisation during urethral Foley catheter insertion is a rare iatrogenic complication, reported predominantly in females with neurogenic bladder. We describe an 80-year-old man with a long-term catheter for benign urethral stricture who presented with abdominal pain and acute kidney injury 24 hours after routine community catheter exchange. Computed tomography demonstrated the inflated balloon within the distal left ureter, with obstructive uropathy. Following repositioning of the catheter, he developed Klebsiella pneumoniae bacteraemia and hypercapnic respiratory failure requiring intensive care, recovered, and was discharged home. The case highlights risks during community catheter management and the value of early cross-sectional imaging.