Perforation of the abdominal viscera is well documented as a rare but important major complication of suprapubic cystostomy [1, 2]. To our knowledge, only one case of delayed bowel perforation has been reported [3] three months after the actual catheter insertion. The likely mechanism is the injury occurred during the original insertion. The catheter and the ensuing inflammatory fibrosis sealed the perforation. On removal of the catheter during the change, the sealed perforation opened up.
Our case explains the increased risk of bowel damage during suprapubic catheterization in patients with history of previous lower abdominal surgery as the bowel frequently adheres to the scar. In one study, it was found that 59% of patients with midline laparotomy incision have anterior abdominal wall adhesions [4]. Therefore, patients with lower abdominal scar should only have suprapubic catheter placement under ideal conditions to reduce risk of bowel perforation. Patients must have adequately distended bladder and placed in Trendelenburg position. We do recommend that the procedure to be performed by a skilled operator using ultrasound scan to look for bowel loops between the bladder and anterior abdominal wall. If bowel loops are present or if ultrasound facilities are not available, then open cystostomy method should be considered. The first change of the catheter should be done in the urology department rather than in the community. Patients returning after having their first catheter change with features of localised peritonitis (lower abdominal pain, high temperature and raised White Blood Cell count) should alert the urologist for the possibility of bowel perforation.