Small bowel perforation during suprapubic tube exchange.

Suprapubic tube placement is a common urological procedure with a low incidence of complications, including hematuria, catheter blockage, recurrent urinary tract infections, and rarely, injury to adjacent organs. Fortunately, most serious complications are discovered shortly after initial suprapubic tube placement and are readily corrected. Very few cases of delayed complications or injuries have been reported. We report a case of Foley perforation into the ileum during suprapubic tube exchange discovered more than 8 months after initial placement, and preceding numerous monthly changes that occurred without incident. While a rare complication, physicians should be conscious of the potential for delayed injury in patients managed with long term suprapubic tube placement.