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

## TL;DR

A case report shows that a urinary catheter can be mistakenly placed in the vagina even when urine flows during insertion, leading to a delayed detection.

## Contribution

This case highlights that urinary outflow during catheterization does not guarantee correct placement in the urethra.

## Key findings

- Urinary outflow during catheterization does not rule out vaginal misplacement.
- Catheter misplacement was only detected after drainage stopped.
- The case emphasizes the need for verification in patients with unclear urethral meatus.

## Abstract

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.

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.

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.