Pneumoretroperitoneum mimicking rectal perforation, secondary to vaginal wall laceration following sexual intercourse in a 19-year-old woman in Korea: a case report
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We report a rare case of pneumoretroperitoneum caused by a vaginal wall laceration following sexual intercourse, including anal intercourse, in a 19-year-old woman. The patient presented with abdominal pain and syncope. Abdominal computed tomography revealed free air in the retroperitoneal space, initially raising suspicion for rectal perforation. However, intraoperative colonoscopy confirmed the rectum was intact. A subsequent gynecological examination identified a 4-cm laceration in the lateral fornix that directly communicated with the retroperitoneal space. The injury was surgically repaired, and the patient achieved a full recovery without complications. This case underscores the importance of considering vaginal trauma in the differential diagnosis of pneumoretroperitoneum, particularly in sexually active young women. A prompt gynecological evaluation can prevent misdiagnosis and unnecessary interventions. In stable patients without signs of infection or peritonitis, conservative management following surgical repair may suffice. To our knowledge, this is the first reported case of pneumoretroperitoneum following sexual intercourse in the absence of rectal injury.
Pneumoretroperitoneum resulting from vaginal trauma is a rare clinical entity. Rectal perforation is a well-recognized cause of retroperitoneal free air, but reports of vaginal wall injuries leading to pneumoretroperitoneum are scarce. Most cases of pneumoretroperitoneum occur secondary to gastrointestinal perforations, postoperative or postprocedural complications, or infections by gas-producing bacteria [1,2]. However, in rare instances, air can enter the retroperitoneal space through a vaginal wall defect, especially after sexual activity, and may mimic rectal injury.
In the present case, a 19-year-old woman was initially thought to have pneumoretroperitoneum due to rectal perforation following anal intercourse. However, intraoperative colonoscopy excluded rectal injury, prompting further evaluation that revealed a vaginal fornix laceration as the source. This case highlights the necessity of considering vaginal trauma in the differential diagnosis of pneumoretroperitoneum and emphasizes the importance of a methodical, stepwise diagnostic approach. This case report thus aims to describe a rare presentation of pneumoretroperitoneum caused by a vaginal wall laceration after sexual intercourse, initially misdiagnosed as rectal perforation.
CASE REPORT
Ethics statement
This study was approved by the Institutional Review Board of Inha University Hospital (No. 2025-06-014), with a waiver for informed consent. All personally identifiable information was collected anonymously. Written informed consent for publication of the research details and clinical images was obtained from the patient.
Patient information
A 19-year-old woman presented to the emergency department with syncope and abdominal pain that developed after sexual intercourse. She reported feeling dizzy, briefly losing consciousness, and then experiencing persistent lower abdominal pain. Her medical history was unremarkable, with no known comorbidities or previous surgery.
Clinical findings
On arrival, her vital signs were stable: blood pressure 115/67 mmHg, pulse rate 65 beats per minute, respiratory rate 18 breaths per minute, and body temperature 36.0 °C. Oxygen saturation was 100% on room air. Physical examination revealed localized tenderness in the lower abdomen without significant rebound tenderness. A small amount of vaginal bleeding was noted, but there was no visible perineal trauma. During history taking, the patient disclosed a history of anal intercourse before symptom onset.
Diagnostic assessment
A digital rectal examination revealed a small amount of bloody clot. Initial laboratory testing showed a hemoglobin level of 12.3 g/dL, a white blood cell count of 17,860/μL, and a C-reactive protein (CRP) level of 0.08 mg/dL. Abdominal and pelvic computed tomography (CT) scans demonstrated multifocal free gas in the perirectal and retroperitoneal spaces, extending up to the pancreatic level (Fig. 1). These findings suggested possible rectal injury. However, there was no evidence of free air in the peritoneal cavity, fluid collection, or peritonitis. Due to high clinical suspicion of rectal perforation, urgent colonoscopy was performed under general anesthesia in the operating room. The rectal mucosa was visualized up to anal verge 40 cm, with no evidence of mucosal injury or perforation. After rectal injury was excluded, a gynecological examination was performed under general anesthesia. This evaluation revealed a 4-cm laceration on the lateral vaginal fornix, with a depth of 2 cm, in direct communication with the retroperitoneal space.
Therapeutic intervention
The vaginal wall laceration was surgically repaired. On the first postoperative day, laboratory testing showed a hemoglobin level of 9.5 g/dL, a white blood cell count of 7,330/μL, and a CRP level of 0.58 mg/dL. On the third postoperative day, the patient complained of dizziness and nausea, raising suspicion for anemia. Angiographic CT was performed, which showed no ongoing bleeding or worsening pneumoretroperitoneum. She received a transfusion of 2 units of packed red blood cells, after which her symptoms improved. By the fifth postoperative day, the patient remained stable without complications and was discharged with outpatient follow-up. Prophylactic antibiotics, including piperacillin-tazobactam, were administered from the day of surgery until discharge to prevent secondary infection.
DISCUSSION
Pneumoretroperitoneum refers to the presence of air within the retroperitoneal space, which can result from various etiologies. The retroperitoneum encompasses structures such as the kidneys, pancreas, aorta, inferior vena cava, and lymph nodes, and is anatomically distinct from the peritoneal cavity [1]. Gastrointestinal perforation, especially involving the retroperitoneal segments of the duodenum or colon, is the most common cause of pneumoretroperitoneum [1,3]. Rectal perforation is also a well-recognized source [4].
Nonsurgical introduction of air, though less common, represents another potential mechanism. Vaginal wall injuries sustained during sexual activity have been reported to permit air entry into the retroperitoneal or peritoneal spaces. Elevated intravaginal pressure during intercourse may cause laceration, particularly in anatomically vulnerable regions such as the lateral fornix. Once disrupted, air can track through the loose areolar tissue adjacent to the vaginal wall and enter the retroperitoneal space [5,6]. In such cases, retroperitoneal air can accumulate even in the absence of visceral perforation [7]. In our patient, no rectal injury was found on intraoperative colonoscopy, and the air was ultimately attributed to a laceration of the vaginal lateral fornix.
Infectious causes must also be considered. Gas-forming organisms can produce emphysematous infections in the retroperitoneum, typically presenting with systemic symptoms such as fever, elevated inflammatory markers, and often a retroperitoneal abscess [7]. Fournier gangrene, a rapidly progressive necrotizing fasciitis of the perineal and genital regions, is a notable infectious cause of retroperitoneal emphysema due to gas propagation along fascial planes. This entity carries high mortality and necessitates urgent surgical debridement; therefore, it must be carefully excluded when retroperitoneal air is detected. While patients with Fournier gangrene typically present with perineal swelling and systemic toxicity, our patient lacked these signs, remained hemodynamically stable, and showed no evidence of infection, making this diagnosis unlikely [8,9].
Management depends on the underlying etiology. If gastrointestinal perforation or infection is suspected, prompt surgical intervention and appropriate antibiotic therapy are required [1,4]. However, when air entry is secondary to non-infectious trauma and ongoing contamination is not present, conservative management may be appropriate.
In this case, multifocal retroperitoneal and perirectal free air extending to the level of the pancreas on imaging initially raised concern for rectal perforation, prompting urgent colonoscopic evaluation under general anesthesia. After rectal integrity was confirmed, a gynecological examination revealed a laceration of the lateral vaginal fornix as the true source of the air. Surgical repair was performed, and the patient remained hemodynamically stable without further complications.
Diagnostic laparoscopy was not performed, as there was no evidence of pneumoperitoneum, hemoperitoneum, or peritonitis on imaging. Nevertheless, it is important to note that the posterior vaginal fornix is situated near the peritoneal cavity, and injuries in this region often result in peritoneal involvement accompanied by hemoperitoneum. In such scenarios, diagnostic laparoscopy is commonly employed to evaluate intraperitoneal injury and facilitate thorough assessment of the vaginal defect. Prophylactic antibiotics were administered to prevent secondary infection [4].
To our knowledge, there have been no previously reported cases of pneumoretroperitoneum occurring after sexual intercourse, including anal intercourse. However, similar instances of vaginal trauma resulting in pneumoperitoneum or pneumoretroperitoneum have been described. Hoffman and Ganti [5] reported a 14-year-old adolescent patient with posterior vaginal fornix perforation and pneumoperitoneum following first sexual intercourse, managed laparoscopically. Symeonidis et al. [10] described a 20-year-old woman with combined vaginal and rectal trauma after intercourse, managed by vaginal repair. Min et al. [6] reported delayed pneumoretroperitoneum in a 7-year-old girl following vaginal trauma, with laparoscopic confirmation of rectal integrity.
Our case is unique in that rectal injury was initially suspected based on imaging but subsequently excluded by direct visualization. Vaginal wall trauma was identified as the true source of the pneumoretroperitoneum. The patient’s stable clinical course and recovery with conservative management after vaginal wall repair underscore the importance of thorough, stepwise evaluation in similar cases.
In conclusion, this case highlights a rare cause of pneumoretroperitoneum in an adolescent, originating from a vaginal wall laceration that occurred during sexual activity. When retroperitoneal air is detected in the emergency setting, especially in the context of recent vaginal or anal intercourse, rectal perforation must be carefully excluded by endoscopic evaluation. A gynecological assessment should be included in the initial workup, as it may identify alternative sources of injury and prevent unnecessary delays in diagnosis or treatment. In the absence of peritoneal signs or systemic infection, conservative management may be appropriate, thereby avoiding unwarranted surgical intervention.
ARTICLE INFORMATION
Author contributions
Conceptualization: SPC, MSC; Methodology: MSC, KES, JCJ, KDK; Writing–original draft: SPC; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Conflicts of interest
The authors have no conflicts of interest to declare.
Funding
The authors received no financial support for this study.
Data availability
Data sharing is not applicable as no new data were created or analyzed in this study.
Fig. 1.
A computed tomography scan taken in a clinic just before the patient's presentation to the main hospital emergency department. (A) Coronal view demonstrating retroperitoneal air (arrows) along the midline and pelvic retroperitoneal space. (B) Axial view of the upper abdomen showing retroperitoneal air adjacent to the aorta and pancreas (arrow). (C) Axial view at the pelvis revealing bilateral retroperitoneal free air near the sacrum, pelvic side walls, and rectum (arrows).
REFERENCES
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3. Jung HC, Kim HJ, Ji SB, et al. Pneumoretroperitoneum, pneumomediastinum, subcutaneous emphysema after a rectal endoscopic mucosal resection. Ann Coloproctol 2016;32:234–8.
7. Yagi Y, Sasaki S, Terada I, et al. Massive pneumoretroperitoneum arising from emphysematous cholecystitis: a case report and the literature review. BMC Gastroenterol 2015;15:114.
10. Symeonidis N, Ballas K, Micha A, Psarras K, Pavlidis T. Consensual intercourse resulting in an extensive rectovaginal tear: an extremely rare occurrence. J Sex Med 2015;12:572–5.
Pneumoretroperitoneum mimicking rectal perforation, secondary to vaginal wall laceration following sexual intercourse in a 19-year-old woman in Korea: a case report
Fig. 1. A computed tomography scan taken in a clinic just before the patient's presentation to the main hospital emergency department. (A) Coronal view demonstrating retroperitoneal air (arrows) along the midline and pelvic retroperitoneal space. (B) Axial view of the upper abdomen showing retroperitoneal air adjacent to the aorta and pancreas (arrow). (C) Axial view at the pelvis revealing bilateral retroperitoneal free air near the sacrum, pelvic side walls, and rectum (arrows).
Fig. 1.
Pneumoretroperitoneum mimicking rectal perforation, secondary to vaginal wall laceration following sexual intercourse in a 19-year-old woman in Korea: a case report
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