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This is considered a surgical emergency, demanding prompt Temozolomide mw control of the perforation and peritoneal toilet. However, there are increasing reports of non-surgical pneumoperitoneum, a condition in which radiographs demonstrate free peritoneal air. These may lead to unnecessary laparotomy but, if correctly diagnosed, can be managed successfully by observation alone.1 We report one such case where a pneumoperitoneum was identified after oro-genital sexual intercourse. A 21-year-old woman with a body mass index of 22.3 presented to hospital complaining of sudden onset right-sided abdominal pain. She was dehydrated and pyrexic at 100��F. The abdomen was asymmetrically distended and tender with peritonitis on the right side. Leukocytosis was present with a white cell count at 16.1?��?103 units. Serum electrolytes, urea, creatinine and amylase levels were normal. She was taken to the operating room for abdominal exploration through a midline laparotomy incision. An enlarged right polycystic kidney was encountered with bossellated surface (Fig. 1). There was pyonephrosis with a thin, translucent renal cortex and a grossly dilated ureter present down to the bladder. The left kidney was mildly enlarged with a normal ureter. No further abnormalities were detected at any other intra-abdominal viscera. Since there was no discernible renal parenchyma and an obvious pyonephrosis, a right nephroureterectomy was performed (Fig. 2). She was discharged home 5 days post-operatively after an uneventful recovery period. Pathologic examination revealed a 12?cm?��?20?cm?��?32?cm right kidney that weighed 4870?g. Histology confirmed pyonephrosis of the kidney with no normal renal cortex. A thin DDR1 translucent membrane Veliparib To our surprise, a large pneumoperitoneum was present, predominantly on the right side (Fig. 4?and?Fig. 5). Clinically she was well. There was no history of colonoscopy, cystoscopy or any other invasive interventions since the time of operation. The abdomen was soft, flat and non-tender (Fig. 6). She had a white cell count of 4.3?��?106?dl�C1 and no evidence of metabolic acidosis. Upon further detailed questioning she admitted to engaging in sexual activity approximately four hours prior to CT scanning. Specifically, there was cunnilingus lasting approximately 15?min and that was followed by regular vaginal intercourse. She denied deliberate vaginal insufflation, anal intercourse or any other sexual acts.