Unintentional Foley catheter placement into a ureter is an extremely rare and life-threatening complication that can be easily prevented by early diagnosis. A misplaced Foley catheter should be suspected in the presence of abdominal pain and oliguria after bladder catheterization, and congenital variation of the urinary tract can complicate this procedure. We reported the third case of misplaced insertion of a Foley catheter into the upper moiety ureter of a duplex kidney in a 19-year-old post-partum woman. The patient complained of the right flank and pelvic pain and oliguria one day after urinary catheter insertion. Duplicated right kidney, upper pole moiety mild hydronephrosis and malpositioned Foley catheter balloon in the right ectopic ureter were reported on ultrasonography which was confirmed by a CT scan. The catheter was removed easily without any complications.
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