Pyometra is an uncommon condition in general population and caused by impairment of natural drainage of the cervix as a result of benign or malignant diseases. Spontaneous uterine perforation, a very rare complication of pyometra, carries signifi cant morbidity and mortality and should be considered in the differential diagnosis of other peritonitis. Preoperative diagnosis of perforated pyometra is diffi cult due to old age, poor general condition, and symptoms that present as abdominal pain related to gastrointestinal diseases. If a diagnosis of perforated pyometra is delayed, then it will be associated with increased morbidity and mortality. In the causes of uterine perforation, pyometra should be considered because of requiring proper intervention. A diagnosis of spontaneous perforated pyometra should always be kept as a possibility in all cases of abdominal pains associated with peritonitis in elderly women.