Pneumoperitoneum Due to Sexual Activity

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

A 27-year-old Caucasian female (CF) is admitted to the hospital with chief complaint (CC) of periumbilical abdominal pain and fever for 2 days.

Detailed questions about the pain - the components of pain can be remembered by the mnemonic SOCRATES:

Site - periumbilical
Onset - gradual
Character - sharp
Radiation - none
Alleviating factors - Pepcid
Timing - getting worse
Exacerbating factors - food
Severity - 7/10
Sx - nausea, no vomiting, diarrhea, fever or chills
Similar symptoms before - yes

Past medical history (PMH)


Social history (SH)

Smoker, IVDA - heroin, uses cocaine. She "failed" several rehab programs.

Physical examination

Chest: CTA (B).
CVS: Clear S1S2.
Abdomen: Soft, diffuse tenderness, no rebound, ND, +BS.
Extremities: no c/c/e.

What diagnostic work-up would you recommend?

CBCD and CMP are normal.
Amylase and lipase are negative.
UA is negative, Cx is pending.
CT scan of the abdomen is negative, apart from showing gallstones.

What happened?

She "spiked" fever on her second hospital day. BC x 2 were drawn.
A CXR was ordered as part of the fever work-up.
EGD was ordered.

Pneumoperitoneum - air under the left hemidiaphragm (click to enlarge the images).

Close-up view of the pneumoperitoneum (click to enlarge the images).

The CXR showed a very small air collection seen in LUQ, below the left hemidiaphragm which was due to a small pneumoperitoneum, and probably related to a recent abdominal intervention.

The problem was that the patient did not have any abdominal intervention. The physical exam did not suggest a hollow viscus perforation.

What would be the next step in the diagnostic evaluation of this patient?

Call the radiologist. The radiologist agreed that it very unlikely that the patient had an organ perforation with a negative physical exam and a CT scan. He recommended repeating the CXR in 2 days.

What was the cause of pneumoperitoneum?

Sexual activity in a female patient.

What happened?

The repeated CXR 2 days later showed a resolution of the pneumoperitoneum. The patient recalled having a sexual intercourse 2 days before the CXR.

The fever was due to UTI, and resolved with antibiotic treatment. EGD was normal.

Final diagnosis

Pneumoperitoneum due to sexual activity.


The term pneumoperitoneum refers to air within the peritoneal cavity. Pneumoperitoneum is usually seen after bowel perforations and surgical procedures.

A pneumoperitoneum is common after abdominal surgery and usually resolves within 3-6 days, although it may persist for as long as 28 days after surgery.

DDx of neumoperitoneum can be remembered by the mnemonic MIST:

- surgery
- peritoneal dialysis

- PUD perforation
- bowel obstruction
- toxic megacolon

- penetrating or blunt injury

- female genital tract (intercourse, douching)
- pneumatosis intestinalis or coli

Typically 4-5 days (up to 4 wks)

Upright CXR or left lateral decubitus can detect 1 cc of gas under diaphragm
- football sign
- Rigler sign

Pneumoperitoneum after sexual intercourse

The available evidence is mostly from case reports. The typical patient is an otherwise healthy woman who comes to the ER, complaining of abdominal pain. Free air under the diaphragm on the X-ray usually leads to costly investigation sometimes resulting in emergency laparotomy without results.

After complete sexual history of the patient is taken, vaginal insufflation during sexual activity is revealed as the cause of the pneumoperitoneum.

Most patients are unaware of the open access between the vagina and abdominal cavity.


Pneumoperitoneum secondary to nonsurgical causes represents a diagnostic dilemma. The majority of patients will require laparotomy which can be avoided with careful history taking and serial abdominal examinations.


Sexual activity as cause for non-surgical pneumoperitoneum. JSLS, 2000.
Pneumoperitoneum after rough sexual intercourse. Am Surg, 2002.
Pneumoperitoneum: a non-surgical cause. MJA 2008; 189 (11/12): 678.
The Football Sign. Radiology 2004;231:81-82.
Pneumatosis coli: a proposed pathogenesis based on study of 25 cases and review of the literature. Int J Colorectal Dis. 1996;11(3):111-8.
Pneumatosis Intestinalis. eMedicine.
The Rigler Sign and Leo G. Rigler. Radiology 2004;233:7-12.
Pneumoperitoneum -, Medical College of Wisconsin.
Pneumoperitoneum. NEJM, Volume 350:e16, April 29, 2004, Number 18.
Falciform-Ligament Sign of Pneumoperitoneum. NEJM Volume 351:e16, October 28, 2004, Number 18.
Ouch! With sex injuries, love really hurts. MSNBC. March 2, 2006.

Published: 01/12/2006
Updated: 05/28/2010


  1. i actually saw one of these once, except she had a totally asymptomatic abdomen. still thought it very strange at the time

  2. OMG, this is exactly what i get after rough intercourse. My abdominal gets swollen and I get sharp (needle pocking sensation) pain. I have pressure the entire time of the swelling and it seems like the pressure moves around and when it comes in contact with a wall that’s when the sharp needle pocking pain comes to take place. The pain and the swelling last for no more than 5 days.

  3. This is a cool case. I have never seen anything like this.

  4. Thank you. Yes, it is a useful case to share and to be aware of this presentation. The full case report was presented during one of the recent SHM annual meetings.

  5. Dr. V, Great case but would be much better if you included an appropriate women's health evaluation. I would expect a gyne hx, sexual hx, intimate partner violence screen, PELVIC EXAM, and STI screening from a good intern in the emergency department who is evaluating (let alone admitting to the hospital) a sexually active female patient w/ abdominal pain and a fever. I am a big fan of your blog but would be a bigger one if you included more women's health/ObGyn content. Thanks! @obgynclerk

  6. А мне кажется это не свободный газ, а газ в желудке.