Urethral catheterization is a technique frequently used in the pediatric emergency department. Intravesicular knotting of the catheter is a rare but potentially preventable complication that can involve significant morbidity. However, because of the relative rarity of this complication there remains a persistent lack of awareness in the pediatric clinical community. The risk of intravesicular catheter knotting can be reduced with proper technique and the correct choice of catheters. We present a case report and list recommendations to minimize the risk of occurrence.
