Change of the suprapubic catheter: Not always safe!

Suprapubic catheterization (SPC) is a commonly used technique for urinary bladder drainage. As an SPC may be needed for long term, the catheter needs to be changed every 2-6 weeks. Change of SPC is a simple and a safe outpatient procedure. Presented here are three unusual complications that occurred when changing the SPC catheter such as catheter getting misplaced up the ureter, balloon extruding outside the urethra and one case of bowel perforation. It is possible that greater awareness of risks and use of a proper technique could have prevented all three complications.