Delay in detection of urethral catheter misplacement in the vagina of an older adult patient due to urinary outflow during catheterization: a case report

Abstract Background To our knowledge, no previous case report explicitly shows that urethral catheter misplacement in the vagina cannot be ruled out even if urinary outflow is observed during catheterization. Case presentation A 70-year-old female underwent urethral catheterization during induction...

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Main Authors: Hisashi Shio, Takao Setsu, Tomonobu Takagaki, Hiroshi Adachi, Makoto Kiuchi, Hideyuki Tsubokura
Format: Article
Language:English
Published: SpringerOpen 2025-02-01
Series:JA Clinical Reports
Subjects:
Online Access:https://doi.org/10.1186/s40981-025-00776-x
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author Hisashi Shio
Takao Setsu
Tomonobu Takagaki
Hiroshi Adachi
Makoto Kiuchi
Hideyuki Tsubokura
author_facet Hisashi Shio
Takao Setsu
Tomonobu Takagaki
Hiroshi Adachi
Makoto Kiuchi
Hideyuki Tsubokura
author_sort Hisashi Shio
collection DOAJ
description Abstract Background To our knowledge, no previous case report explicitly shows that urethral catheter misplacement in the vagina cannot be ruled out even if urinary outflow is observed during catheterization. Case presentation A 70-year-old female underwent urethral catheterization during induction of general anesthesia for hemiarthroplasty using a bipolar hip prosthesis. Although the urethral meatus could not be visualized, urinary outflow was observed. However, drainage subsequently stopped, and the catheter was eventually found to have been misplaced in the vagina. Detection of the catheter misplacement was delayed because of the assumption that no urinary outflow occurs when the catheter is misplaced in the vagina. Conclusion Even if urinary outflow is observed during female urethral catheterization, catheter misplacement in the vagina cannot be ruled out; therefore, catheter misplacement in the vagina must be verified in patients for whom the urethral meatus cannot be identified for catheter insertion or when drainage stops.
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spelling doaj-art-110bed30f2a44e9f8b92e79256d27a242025-08-20T02:16:45ZengSpringerOpenJA Clinical Reports2363-90242025-02-011111510.1186/s40981-025-00776-xDelay in detection of urethral catheter misplacement in the vagina of an older adult patient due to urinary outflow during catheterization: a case reportHisashi Shio0Takao Setsu1Tomonobu Takagaki2Hiroshi Adachi3Makoto Kiuchi4Hideyuki Tsubokura5Department of Anesthesiology, Tottori Red Cross HospitalDepartment of Anesthesiology, Tottori Red Cross HospitalDepartment of Anesthesiology, Tottori Red Cross HospitalDepartment of Anesthesiology, Tottori Red Cross HospitalDepartment of Obstetrics and Gynecology, Tottori Red Cross HospitalDepartment of Anesthesiology, Tottori Red Cross HospitalAbstract Background To our knowledge, no previous case report explicitly shows that urethral catheter misplacement in the vagina cannot be ruled out even if urinary outflow is observed during catheterization. Case presentation A 70-year-old female underwent urethral catheterization during induction of general anesthesia for hemiarthroplasty using a bipolar hip prosthesis. Although the urethral meatus could not be visualized, urinary outflow was observed. However, drainage subsequently stopped, and the catheter was eventually found to have been misplaced in the vagina. Detection of the catheter misplacement was delayed because of the assumption that no urinary outflow occurs when the catheter is misplaced in the vagina. Conclusion Even if urinary outflow is observed during female urethral catheterization, catheter misplacement in the vagina cannot be ruled out; therefore, catheter misplacement in the vagina must be verified in patients for whom the urethral meatus cannot be identified for catheter insertion or when drainage stops.https://doi.org/10.1186/s40981-025-00776-xOlder adult patientFemale urethral catheterizationDifficult urethral catheterizationUretheral catheter misplacement in the vaginaVesicovaginal refluxUrinary incontinence
spellingShingle Hisashi Shio
Takao Setsu
Tomonobu Takagaki
Hiroshi Adachi
Makoto Kiuchi
Hideyuki Tsubokura
Delay in detection of urethral catheter misplacement in the vagina of an older adult patient due to urinary outflow during catheterization: a case report
JA Clinical Reports
Older adult patient
Female urethral catheterization
Difficult urethral catheterization
Uretheral catheter misplacement in the vagina
Vesicovaginal reflux
Urinary incontinence
title Delay in detection of urethral catheter misplacement in the vagina of an older adult patient due to urinary outflow during catheterization: a case report
title_full Delay in detection of urethral catheter misplacement in the vagina of an older adult patient due to urinary outflow during catheterization: a case report
title_fullStr Delay in detection of urethral catheter misplacement in the vagina of an older adult patient due to urinary outflow during catheterization: a case report
title_full_unstemmed Delay in detection of urethral catheter misplacement in the vagina of an older adult patient due to urinary outflow during catheterization: a case report
title_short Delay in detection of urethral catheter misplacement in the vagina of an older adult patient due to urinary outflow during catheterization: a case report
title_sort delay in detection of urethral catheter misplacement in the vagina of an older adult patient due to urinary outflow during catheterization a case report
topic Older adult patient
Female urethral catheterization
Difficult urethral catheterization
Uretheral catheter misplacement in the vagina
Vesicovaginal reflux
Urinary incontinence
url https://doi.org/10.1186/s40981-025-00776-x
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