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Even if acute abdomen is associated with gastrointestinal (GI) perforation in more than 90% of cases, spontaneously perforated pyometra is a rare and misleading cause that gynecologists and general surgeons should suspect in elderly postmenopausal women. We report one case of diffuse peritonitis caused by spontaneous uterine perforation. A 94-year-old postmenopausal female was admitted to emergency department with signs of diffuse peritonitis and seven days history of abdominal pain. Abdominal contrast- enhanced CT-scan showed a large amount of ascites and a small amount of intraperitoneal free-air. One hour after the admission septic shock developed and emergency laparotomy was performed for suspected GI perforation. During laparotomy about 1500 mL of purulent, malodorous but not-fecaloid fluid was found in peritoneal cavity, without evidence of GI perforation. A 10 mm perforation on the anterior part of the uterine fundus was found. A total abdominal hysterectomy with a bilateral salpingo-oophorectomy was performed. Patients died on postoperative day four despite intensive care for multi-organ failure due to septic shock. The hysto-pathology examination showed absence of cancer. Pyometra perforation is a rare cause of acute abdomen with a not negligible mortality and it should be considered in the differential diagnosis of acute abdomen, especially in elderly patients. The aim of the study is to report our personal experience and a review of the literature of spontaneous perforation of pyometra in patients with no evidence of malignancy.