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Abstract Background Colonic perforation usually presents with classical signs of peritonitis. However, isolated retroperitoneal colonic perforation can present with varied clinical signs and symptoms and pose diagnostic challenges. Pneumo-mediastinum and abdominal subcutaneous emphysema can be one of the presenting signs of colonic perforation. Case report A 33-year-old male presented with abdominal distension and extensive subcutaneous emphysema over the abdomen, pneumo-mediastinum, and pneumo-scrotum secondary to sigmoid colon perforation from a foreign body. The patient did not have classical signs of peritonitis. Conclusion Being vigilant about the potential of colonic perforation is crucial when observing a significantly increasing subcutaneous emphysema across different parts of the body. Attending clinicians should always keep intraabdominal pathology in mind when a direct cause for these symptoms cannot be found and the patient’s symptoms become progressive.