Sexual Activity as Cause for Non-Surgical Pneumoperitoneum

Abstract

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.
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.
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.

Full text

Sexual Activity as Cause for Non-Surgical
Pneumoperitoneum
JSLS (2000)4:297-300 297
ABSTRACT
Background: Pneumoperitoneum is usually seen after
bowel perforations and surgical procedures. An increas-
ing 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 laparoto-
my without any results. Finally, after thorough discus-
sion 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 CO
2
-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 sex-
ually active women, a careful inquiry into the medical-
sexual history can reveal the cause of pathophysiology
without comprehensive, painful and unnecessary diag-
nostics. Sexual history as a diagnostic tool should always
be considered in unclear cases.
Key Words: Non-surgical pneumoperitoneum, Oro-
vaginal insufflation, Sexual activity, Gas embolism,
Pregnancy.
BACKGROUND
Pneumoperitoneum, often seen in acute gastrointestinal
perforation, requires in about 90% of cases urgent surgi-
cal intervention. However, in 10% of cases, pneu-
moperitoneum has a different cause.
1,2
Possible gyneco-
logic causes are knee-chest exercises, pelvic inflammato-
ry disease, coitus, gynecologic examination procedures,
vaginal douching and vaginal insufflation.
1
Due to a
trend toward more experimental sexual activity and less
taboo in media and society about this topic, an increas-
ing number of reports of non-surgical pneumoperi-
toneum connected to sexual activities has been
described within the last years worldwide.
We reviewed such case reports to reveal the patho-mech-
anism 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.
CASE EXAMPLE
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 dura-
tion. The pain was described as sharp, diffuse, initially
worse in the right lower quadrant and then becoming
generalized. There was no associated nausea, vomiting,
chills or fever. Movement aggravated the pain with no
relenting factors. The pain was continuous. 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 36.5°C.
Her abdomen had decreased bowel sounds and was dif-
fusely tender with rebound tenderness and involuntary
guarding in all quadrants. Pelvic and rectal examination,
including lab, were normal.
An upright chest X-ray demonstrated free air under the
diaphragm. An abdominal radiograph showed signs
indicative of non-surgical pneumoperitoneum.
Her past medical history was remarkable for pneu-
Director of Frauenklinik (Prof. Dr. Jonat).
Address reprint request to: Dr. Volker R. Jacobs, Frauenklinik (OB/GYN), Christian-
Albrechts-University, Michaelisstr. 16, 24105 Kiel, Germany. Telephone: +49-431-
597-2100, Fax: +49-431-597-2146, E-mail volkerjacobs@hotmail.com
© 2000 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
Volker R. Jacobs, MD, Christoph Mundhenke, MD, Nicolai Maass, MD,
Felix Hilpert, MD, Walter Jonat, MD

Sexual Activity as Cause for Non-Surgical Pneumoperitoneum, Jacobs VR et al.
298 JSLS (2000)4:297-300
moperitoneum 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 X-
ray revealed pneumoperitoneum. On both occasions, the
patient underwent laparotomy; but, despite comprehen-
sive diagnostics, no cause was found.
On further questioning, a complete sexual history was
obtained. The patient revealed that she had intercourse,
during which her partner forcefully blew air into her vagi-
na prior to all episodes of pneumoperitoneum. She
remembered that the pain had started four hours after
each occasion.
Under close conservative observation, the pain disap-
peared within 24 hours and repeated abdominal X-ray
showed spontaneous absorption of pneumoperitoneum.
The patient was discharged with instructions to avoid fur-
ther cunnilingus with oro-vaginal insufflation.
3
DISCUSSION
Cunnilingus is a common sexual practice all over the
world. During such activity, whereby gas can be force-
fully 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 knowl-
edge of the open access between the vagina and
abdomen, and the medical staff is often inadequately
informed on the patho-mechanism. Primarily, pneu-
moperitoneum — 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 usu-
ally forceful gas insufflation, but also during sexual inter-
course,
4
intercourse in rear entry position,
5
by hand or
during drug abuse via oro-vaginal cocaine insufflation.
6
2) Through openings at the vaginal stump after abdom-
inal
7
or vaginal
4,8
hysterectomy
7-12
(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
Figure 1. Entrance path for gas along the normal anatomical
way through vagina, uterus and fallopian tubes.
Figure 2. Entrance path for gas through small lacerations at
vaginal stump after hysterectomy.

pressure the uterus-placenta connection, enters the uter-
ine veins, leading to fatal gas embolism,
5-6,13-17
fatal also
for women early post partum.
18-19
In Figure 1 and Figure 2, the insufflation of gas usually
leads only to painful but uncomplicated pneumoperi-
toneum of limited duration. However, in Figure 3, gas
insufflation can lead to fatal gas embolism.
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 hysterecto-
my, 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 CO
2
gas — as used in laparoscopy — is pulmonary
completely eliminated within one to two hours at aver-
JSLS (2000)4:297-300 299
age resorption rates of 37 ml/min with peaks up to 223
ml/min.
20
However, pneumoperitoneum resorption of
normal room air takes up to one week. An upright
chest-abdomen X-ray usually detects pneumoperi-
toneum, but CT has the highest sensitivity.
21
A manage-
ment for post-coital pneumoperitoneum and an algo-
rithm to avoid laparotomies have been published.
22,23
Because of usually unspecific and minor symptoms, the
patho-mechanism of gas embolism through vaginal insuf-
flation 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 gynecolo-
gy, they could be hidden in the group of repeated
laparoscopies for adhesiolysis or chronic, unspecific
pelvic pain.
Although patients with acute non-surgical pneumoperi-
toneum are usually first seen by internal or surgical
physicians in the emergency room, interdisciplinary con-
sultation with other specialists such as obstetric/gyneco-
logic, ear, nose and throat (ENT) or thoracic surgeons
should be considered to eliminate other reasons of non-
surgical pneumoperitoneum. Conservative treatment
with close observation of vital signs and upright chest-
abdomen X-ray with evidence of resorption of pneu-
moperitoneum is adequate. Prophylactic antibiotics are
not necessary. Thorough patient education before dis-
charge 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 pneumoperi-
toneum 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 col-
league or nurse present during the questioning and to
document this in the patient charts.
Clarification and open discussion about the risk of vagi-
nal insufflation might prevent sexual pneumoperi-
toneum. 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
Figure 3. Entrance path for gas through uterine veins during
pregnancy and early post partum.

Sexual Activity as Cause for Non-Surgical Pneumoperitoneum, Jacobs VR et al.
300 JSLS (2000)4:297-300
leaflets. Facts about the patho-mechanism and potential-
ly dangerous consequences of vaginal pressure insuffla-
tion should be made available to all sexually active
women, especially to patients at risk (eg, during preg-
nancy, post partum and post hysterectomy). At the pres-
ent time, mandatory information for all women seems
neither necessary nor possible.
CONCLUSION
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 atyp-
ical non-surgical pneumoperitoneum in sexually active
women, a sensitive sexual medical history can reveal
the cause for non-surgical pneumoperitoneum.
Comprehensive, expensive, painful, invasive and unnec-
essary diagnostics and procedures can be avoided. For
this reason, more attention should be given to sexual his-
tory, especially as a diagnostic tool in unclear cases of
pneumoperitoneum.
References:
1. Mularski RA, Ciccolo ML, Rappaport WD. Nonsurgical caus-
es of pneumoperitoneum. West J Med. 1999;170:41-46.
2. Rowe NM, Kahn FB, Acinapura AJ, Cunningham JN Jr.
Nonsurgical pneumoperitoneum: a case report and a review.
Am Surg. 1998;64:313-322.
3. Varon J, Laufer MD, Sternbach GL. Recurrent
Pneumoperitoneum following vaginal insufflation. Am J Emerg
Med. 1991;9:447-448.
4. Tabrisky J, Mallin LP, Smith JA III. Pneumoperitoneum after
coitus: a complication due to uterine prolapse after vaginal hys-
terectomy. Obstet Gynecol. 1972;40:218-220.
5. Lifschultz BD, Donoghue ER. Air Embolism during inter-
course in pregnancy. J Forens Sci. 1983;28:1021-1022.
6. Collins KA, Davis GJ, Lantz PE. An unusual case of mater-
nal-fetal death due to vaginal insufflation of cocaine. Am J Forens
Med and Path. 1994;15(4):335-339.
7. Apesos J, Srivastava JK, Williams C, Patton RJ. Postcoital
pneumoperitoneum. Obstet Gynecol. 1980;55(Suppl 3):47S-49S.
8. Christiansen WC, Danzl DF, McGee HJ. Pneumoperitoneum
following vaginal insufflation and coitus. Ann Emerg Med.
1980;9:480-482.
9. Babarinsa IA, Ajayi AB, Adeleye JA. Coitally-related morbidi-
ties in the non-pregnant female. West Afr J Med. 1995;14:141-146.
10. Borowski GD, Veloso A, Nothmann BJ. Recurrent pneu-
moperitoneum after hysterectomy. J Clin Gastroenterol.
1983;5:81-82.
11. Spaulding LB, Gallup DG. Pneumoperitoneum after hys-
terectomy. JAMA. 1979;241:825.
12. Nicolsen SC, Gillmer MDG. Management of postcoital pneu-
moperitoneum following hysterectomy. J Obstet Gynecol.
1993;13(4):289-290.
13. Fyke FE III, Kazmier FJ, Harms RW. Venous air embolism:
life threatening complication of orogenital sex during pregnancy.
Am J Med. 1985;78:333-336.
14. Hill BF, Jones JS. Venous air embolism following orogenital
sex during pregnancy. Am J Emerg Med. 1993;11(2):155-157.
15. Kaiser RT. Air embolism death of a pregnant woman sec-
ondary to orogenital insufflation. Acad Emerg Med.
1994;1(6):555-558.
16. Eckert WG, Katchis S, Dotson P. The unusual accidental
death of a pregnant woman by sexual foreplay. Am J Forens
Med Pathol. 1991;12(3):247-249.
17. Fatteh A, Leach WB, Wilkinson CA. Fatal air embolism in
pregnancy resulting from orogenital sex play. Forens Sci.
1973;2(2):247-250.
18. MacGregor JS, Wu AW, Rubin HR. Pleuritic chest pain in a
postpartum woman. Arch Emerg Med. 1991;8:271-273.
19. Batman PA, Thomlinson J, Moore VC, Sykes R. Death due
to air embolism during sexual intercourse in the puerperium.
Postgrad Med J. 1998;74:612-613.
20. Weyland W, Crozier TA, Bräuer A, et al. Anästhesiologische
besonderheiten der operativen phase bei laparoskopischen oper-
ationen. Zentralbl Chir. 1993;118:582-587.
21. Earls JP, Dachman AH, Colon E, Garrett MG, Molloy M.
Prevalence and duration of postoperative pneumoperitoneum:
sensitivity of CT. Am J Roentgenol. 1993;161:781-785.
22. Nicolsen SC, Gillmer MDG. Management of postcoital pneu-
moperitoneum following hysterectomy. J Obstet Gynecol.
1993;13(4):289-290.
23. Hoover EL, Cole GD, Mitchell LS, Adams CZ, Hassett J.
Avoiding laparotomy in nonsurgical pneumoperitoneum. Am J
Surg. 1992;164:99-103.
Prior Presentation: Poster presentation at Endo Expo ‘99, 8th
International Meeting of the Society of Laparoendoscopic
Surgeons, New York, NY, December 4-7, 1999.