Urinary catheterization using an infant feeding tube is a familiar practice in neonatal and pediatric settings, particularly when appropriately sized urinary catheters are unavailable. But what happens when the tube inserted into the bladder cannot be pulled out? This rare case highlights an unusual but potentially serious complication— spontaneous intravesical knotting of an infant feeding tube. The Case A 3-month-old male infant admitted with acute febrile illness and seizures underwent transurethral catheterization using a 6 Fr infant feeding tube for urine collection and output monitoring.

Approximately two days later, resistance was encountered during attempted catheter removal. Further evaluation revealed that the tube had been inserted approximately 12 cm into the bladder. A pelvic X-ray demonstrated catheter coiling consistent with intravesical knotting . Gentle traction was…