Perforation of the urinary bladder is a rare complication with a considerable degree of morbidity and mortality in modern neonatal intensive care units. We report a case of urinary bladder perforation, which probably was triggered by prolonged urinary retention secondary to morphine infusion, using credé maneuver on an already over-distended bladder, and inserting an umbilical catheter as urethral catheterization in an extremely low birth weight infant.