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an increasing number of cases of non - surgical pneumoperitoneum related to sexual activity has been reported worldwide over the last years .
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 .
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 .
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
pneumoperitoneum , often seen in acute gastrointestinal perforation , requires in about 90% of cases urgent surgical intervention .
possible gynecologic causes are knee - chest exercises , pelvic inflammatory disease , coitus , gynecologic examination procedures , vaginal douching and vaginal insufflation . due to a trend toward more experimental sexual activity and less taboo in media and society about this topic , an increasing number of reports of non - surgical pneumoperitoneum connected to sexual activities has been described within the last years worldwide .
we reviewed such case reports to reveal the patho - mechanism and to stress the importance of a sexual medical history to prevent unnecessary invasive diagnostics and surgery .
the number of publications about this topic demonstrates the danger of ( oro- ) vaginal insufflation and identifies the groups at risk .
a typical case example is that of a 24-year - old woman , 0 gravid , who appeared in the emergency department complaining of severe abdominal pain of 6 hours duration .
the pain was described as sharp , diffuse , initially worse in the right lower quadrant and then becoming generalized .
her last menstrual period was six days prior to admission with normal flow , timing and duration .
the vital signs were normal : blood pressure 110/70 , pulse 100/min , respiration 24/min , temperature 36.5c .
her abdomen had decreased bowel sounds and was diffusely tender with rebound tenderness and involuntary guarding in all quadrants .
her past medical history was remarkable for pneumoperitoneum accompanying similar episodes of pain 6 and 12 months prior to this event .
the patient appeared each time with abdominal pain of acute onset and the xray revealed pneumoperitoneum . on both occasions , the patient underwent laparotomy ; but , despite comprehensive diagnostics , no cause was found . on further questioning
the patient revealed that she had intercourse , during which her partner forcefully blew air into her vagina prior to all episodes of pneumoperitoneum .
she remembered that the pain had started four hours after each occasion . under close conservative observation ,
the pain disappeared within 24 hours and repeated abdominal x - ray showed spontaneous absorption of pneumoperitoneum .
the patient was discharged with instructions to avoid further cunnilingus with oro - vaginal insufflation .
whereby gas can be forcefully blown into the vagina by mouth or insufflated by other mechanisms , unintended large amounts of gas can be forced under pressure into the vagina
. the gas can find its way through the uterus and , after dilating the tubes , into the abdomen , thereby causing a non - surgical pneumoperitoneum .
the patient often has no knowledge of the open access between the vagina and abdomen , and the medical staff is often inadequately informed on the patho - mechanism .
primarily , pneumoperitoneum  without prior surgery  is normally associated with the potential danger of perforation of intestinal organs and , therefore , often leads to emergency laparotomy .
the publications reviewed show three potential gas paths : 1 ) through vagina , uterus and fallopian tubes into the abdomen ( figure 1 ) .
patho - mechanism is usually forceful gas insufflation , but also during sexual intercourse , intercourse in rear entry position , by hand or during drug abuse via oro - vaginal cocaine insufflation.2 ) through openings at the vaginal stump after abdominal or vaginal hysterectomy 
 ( figure 2 ) .
patho - mechanism is vaginal gas pressure insufflation , which can open small lacerations at the vaginal stump .
3 ) through the uterine veins during pregnancy and early post partum ( figure 3 ) . patho - mechanism is gas that dilates under pressure the uterus - placenta connection , enters the uterine veins , leading to fatal gas embolism , fatal also for women early post partum .
entrance path for gas along the normal anatomical way through vagina , uterus and fallopian tubes .
entrance path for gas through uterine veins during pregnancy and early post partum . in figure 1 and figure 2
, the insufflation of gas usually leads only to painful but uncomplicated pneumoperitoneum of limited duration .
the potential entrance paths for gas identifies the groups at risk : 1 ) forceful ( oro- ) vaginal insufflation in any woman ; 2 ) patients who have undergone a hysterectomy , independent of operation technique ; and 3 ) pregnant and early post partum women .
( oro- ) vaginal insufflation is especially dangerous during pregnancy , because large amounts of gas can easily penetrate into the uterine veins and cause lethal gas embolism .
intra - abdominal gas resorption from pneumoperitoneum takes up to several days , depending on content of gas .
pure co2 gas  as used in laparoscopy  is pulmonary completely eliminated within one to two hours at average resorption rates of 37 ml / min with peaks up to 223 ml / min .
an upright chest - abdomen x - ray usually detects pneumoperitoneum , but ct has the highest sensitivity .
a management for post - coital pneumoperitoneum and an algorithm to avoid laparotomies have been published .
because of usually unspecific and minor symptoms , the patho - mechanism of gas embolism through vaginal insufflation is rarely identified until post mortem during autopsy . after reviewing the references
, this patho - mechanism must be more frequent than so far expected , probably overlooked or unrecognized due to minor or unspecific complaints that are of limited duration until gas resorption is completed . in obstetrics and gynecology ,
they could be hidden in the group of repeated laparoscopies for adhesiolysis or chronic , unspecific pelvic pain . although patients with acute non - surgical pneumoperitoneum are usually first seen by internal or surgical physicians in the emergency room , interdisciplinary consultation with other specialists such as obstetric / gynecologic , ear , nose and throat ( ent ) or thoracic surgeons
conservative treatment with close observation of vital signs and upright chest - abdomen x - ray with evidence of resorption of pneumoperitoneum is adequate .
thorough patient education before discharge from the hospital can prevent a repeat of similar events . in cases of non - surgical pneumoperitoneum related to sexual activities
, a careful sexual medical history might reveal the cause and patho - mechanism of pneumoperitoneum and so help to avoid expensive and unnecessary emergency laparotomy .
the different mechanisms of pneumoperitoneum should be explained sensitively to the patient , allowing her to understand the reason for the questioning . nevertheless ,
because of the delicacy of this topic , it is advisable for legal reasons to have a colleague or nurse present during the questioning and to document this in the patient charts . clarification and open discussion about the risk of vaginal insufflation might prevent sexual pneumoperitoneum .
information about the open access between the vagina and abdomen should be part of sexual education at school and should be elucidated in patient information leaflets .
facts about the patho - mechanism and potentially dangerous consequences of vaginal pressure insufflation should be made available to all sexually active women , especially to patients at risk ( eg , during pregnancy , post partum and post hysterectomy ) . at the present time
sexual pneumoperitoneum is not a bizarre sex accident but a rare and serious patho - mechanism .
vaginal gas insufflation can lead to dangerous and fatal gas embolism , especially during pregnancy . in cases of atypical non - surgical pneumoperitoneum in sexually active women ,
comprehensive , expensive , painful , invasive and unnecessary diagnostics and procedures can be avoided .
for this reason , more attention should be given to sexual history , especially as a diagnostic tool in unclear cases of pneumoperitoneum .
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 .