Traumatic indwelling catheterisation (IDC), though routine, poses significant risks, especially among elderly patients with complex urological histories. This case illustrates a fatal rectal perforation and subsequent septic shock following catheterisation, highlighting critical vulnerabilities in existing clinical protocols and the urgent necessity for enhanced education, refined insertion techniques, and robust preventive measures.

We present a detailed analysis of a 96-year-old male patient with a complex history including prostatomegaly, chronic obstructive pulmonary disease, previous bowel resection, and long-term IDC use. Following dislodgement at a nursing facility, multiple traumatic catheter insertion attempts led to acute presentation characterised by urethral bleeding, sepsis, and hypovolaemia. Clinical assessments encompassed CT imaging, cystoscopic evaluation, and comprehensive microbiological investigations to elucidate the cause and trajectory of his rapid clinical deterioration.

CT imaging confirmed a rectal perforation and extensive surgical emphysema resulting from misdirected catheterisation attempts. Blood cultures identified Providencia rettgeri and Enterococcus faecalis bacteraemia, prompting escalation of antibiotic therapy and multidisciplinary management involving urology, surgery, infectious disease, and intensive care. Despite aggressive interventions, including IDC replacement under cystoscopic guidance and targeted antimicrobial therapy, the patient succumbed rapidly to septic shock. Root cause analysis identified critical gaps in IDC insertion technique, inadequate specialist catheter availability (coudé-tipped catheters), and insufficient catheterisation training among community care staff.

This case underscores the potentially fatal consequences of traumatic IDC insertion and highlights an urgent need for enhanced education, revised insertion protocols, and interdisciplinary management guidelines. Implementation of specialist IDC training programs, availability of appropriate catheter types, and mandatory early urological consultation following traumatic insertions are essential to prevent similar catastrophic outcomes. Increased vigilance and systematic improvements in catheter management practices are paramount in safeguarding patient safety.