Background: Pneumoperitoneum is usually seen after bowel perforations and surgical procedures. An increasing number of cases of non-surgical pneumoperitoneum related to sexual activity has been reported worldwide over the last years. CASE EXAMPLE: A typically young, otherwise healthy woman comes into the emergency department of Stanford University, California, complaining of recurrent chest pain. Free air under the diaphragm disclosed in the X-ray usually leads to intensive, costly and invasive diagnostics sometimes resulting in emergency laparotomy without any results. Finally, after thorough discussion of the sexual history of the patient is taken, vaginal insufflation during sexual activity is revealed as the cause of non-surgical pneumoperitoneum.
Discussion: Patients are often unaware of the open access between the vagina and abdomen. Insufflation pressure during vaginal insufflation with >100 mm Hg--used as a diagnostic tool in CO2-pertubation--can dilate genital organs and push remarkable amounts of air into the abdomen. Gas resorption can take up to several days, and the patient often does not connect the pain to its cause. Embarrassment and modesty often prevent the patient from talking about sexual activity.
Conclusion: Sexual pneumoperitoneum is not a bizarre sex accident but a rare and serious patho-mechanism. In cases of atypical non-surgical pneumoperitoneum in sexually active women, a careful inquiry into the medical-sexual history can reveal the cause of pathophysiology without comprehensive, painful and unnecessary diagnostics. Sexual history as a diagnostic tool should always be considered in unclear cases.