A tale of two catheters: STEMI in a patient presenting with acute urinary retention.

ST-segment elevation myocardial infarction (STEMI) classically presents with chest pain, yet 10-13% of patients present without it, leading to delayed diagnosis and worse outcomes. We report a 59-year-old man with prostate cancer who presented to the emergency department (ED) via emergency medical services (EMS) with acute penile and suprapubic pain from urinary retention. He denied chest pain, dyspnea, and other cardiac symptoms throughout his encounter. A prehospital 12‑lead electrocardiogram (ECG) revealed ST-segment elevations in leads II, III, and aVF, prompting a STEMI alert. In the ED, bladder ultrasonography confirmed distention, and Foley catheter placement resolved his obstruction and pain. Despite complete symptom resolution, persistent ST elevation prompted emergent catheterization, which revealed 100% occlusion of the right coronary artery (RCA). This case illustrates painless STEMI, the diagnostic value of prehospital ECG in patients with non-cardiac complaints, and the principle that persistent objective evidence of ischemia must not be dismissed when an alternative pain source is treated.