Background Transvaginal intestinal evisceration is an extremely rare surgical emergency with potentially fatal consequences. Only a few more than 100 cases with this pathology have been described in the literature. Aetiology is also unclear and multifactoral. Case presentation We report the case of an 80-year-old female who presented with sudden severe abdominal pain and spontaneous small bowel evisceration through the vagina along with associated high-grade uterine prolapse. The loops and their mesentery appeared edematous, thickened and dusky, but without apparent necrosis. An urgent laparotomy was performed with subsequent reduction of the prolapsed small bowel into the abdomen, hysterectomy, partial resection of the vagina and vaginal closure. Additional cholecystectomy was necessary because of the visible pathologic changes of the gallbladder. The postoperative period was uneventful. The unique feature of our case is that there was no trigger factor (trauma, constipation or a coughing episode that would increase the intra-abdominal pressure), provoking the vaginal rupture and intestinal evisceration through it in the context of pelvic floor weakness. Conclusions Early detection and surgical management are crucial for preventing bowel ischemia and abdominal sepsis. If the eviscerated intestine is ischaemic and non-viable, this requires resection and anastomosis. The approach should be individualized and performed by a multidisciplinary team.