BACKGROUND Acute aortic syndrome (AAS) is a spectrum of severe life-threatening disease processes that are often initially encountered in the emergency department (ED) setting and require prompt recognition and treatment to prevent significant complications, including death. We describe an atypical presentation of aortic intramural hematoma in a female patient during sexual intercourse, a situation not previously described in the literature. CASE REPORT The patient was a 45-year-old woman who presented to the ED with a chief concern of chest pain. Just prior to the onset of her symptoms, the patient was having sexual intercourse with her husband, and during her orgasm she felt a "pop" in her chest with radiation to her back. The patient was diaphoretic and hypertensive on arrival, with a blood pressure of 220/140 mmHg. Computed tomography angiography of the chest was performed and showed an intramural hematoma (or thrombosed dissection) of the distal aortic arch and descending thoracic aorta. In the ED, the patient was started on intravenous antihypertensives, which were eventually switched to oral agents. Cardio-thoracic surgery staff was consulted and recommended medical management. As oral doses were increased, the intravenous antihypertensives were weaned, and the patient was eventually discharged home with scheduled outpatient follow-up. CONCLUSIONS Intramural aortic hematoma is a form of AAS with independent pathogenesis but similar progression, complications, and treatment as aortic dissection and thus demands efficient diagnosis and treatment. A high degree of suspicion, even in atypical situations, is paramount, as efficient recognition and treatment can be lifesaving.