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Infant feeding tubes are routinely used as urethral catheters in neonates and children. Although considered safe, it can lead to significant morbidity if the catheter knots in the bladder. We report a case of a spontaneous urinary catheter knotting in a neonate. It required a perineal urethrotomy for successful removal.  A lateral oblique radiograph to characterize the complexity of knot helps in its management. Training of staff involved in the insertion, maintenance or removal of the catheters is essential to decrease catheter related complications.

Spontaneous intraurethral catheter knot requiring perineal urethrotomy in a neonate: A case report with review of management and prevention