Summary

Insertion of a peritoneal dialysis (PD) catheter into the bladder is a rare complication of PD. Herein, we describe a case of an adult patient undergoing PD tube insertion who was found to have the catheter in the urinary bladder. He was treated with PD catheter removal, prophylactic antibiotics and repair of the bladder wall. This report gives a timely reminder of and the need to check for urinary bladder distension prior to PD catheter insertion surgery. Perforating injuries should be considered in patients with symptoms related to the urinary tract and free flow of fluid from the PD tube.