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Suprapubic cystostomy is commonly performed in patients with neurogenic bladder or bladder outlet obstruction. The most serious complication is bowel injury, which usually occurs during catheter insertion. Bowel perforation during suprapubic catheter exchange is rare. We herein report an extremely rare case of terminal ileal perforation resulting from a change of suprapubic catheter. After insertion of the suprapubic catheter, a feculent material was noted in the terminal ileum. A cystography revealed that the contrast medium passed directly into the terminal ileum and colon. A computed tomographic scan confirmed the presence of a balloon tip in the terminal ileum. Terminal ileum perforation was diagnosed. Emergent laparotomy and loop ileostomy were performed. The patient's recovery was uneventful.