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What Is the Pouch of Douglas?

Mary McMahon
By
Updated Mar 03, 2024
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The pouch of Douglas is the lowest area of the peritoneal cavity in women. It is a small extension of the peritoneal cavity which lies between the uterus and the rectum. This structure is named after Dr. James Douglas, a Scottish physician who worked in the 18th century and was especially interested in this area of the anatomy. Several other anatomical features are named for Dr. Douglas, recognizing his contributions to the understanding of human anatomy.

Terms such as “rectouterine pouch” and “cul de sac” are sometimes used to refer to the pouch of Douglas. The structure is long and narrow, open at the top and closed at the bottom. Because of its position at the bottom of the peritoneal cavity, it can serve as a drainage point for fluids in the cavity. This can lead to medical problems; malignant growths may spread to the pouch of Douglas, and women can experience discomfort if the pouch of Douglas fills with fluid, pus, and other materials.

Due to concerns about the fact that the pouch of Douglas can act as a collection point for materials in the peritoneal cavity, a doctor may recommend examination of the area if a woman has a medical issue which involves the peritoneal cavity. The examination can be used to determine whether or not the pouch of Douglas has become involved, and to identify emerging complications which could threaten reproductive health, such as infections which could penetrate the uterine wall.

In a procedure known as peritoneal dialysis which is sometimes used to treat kidney failure, the peritoneal cavity is regularly bathed with a dialysate solution which may be introduced through the pouch of Douglas in women. In this case, a catheter is placed into the structure and is used as a semi-permanent port to introduce dialysate fluid and to allow for drainage of the fluid.

In a procedure known as culdoscopy, an endoscope is introduced to the pouch of Douglas through the vagina for the purpose of examining the interior. This may be done for the purpose of preparing for a procedure such as a fluid drainage, or to look for signs of abnormalities which could be involved in a medical diagnosis. The structure can also be visualized with a medical imaging study such as an MRI scan if a doctor suspects that a woman has endometriosis, adhesions, or other abnormalities inside the pouch of Douglas.

How To Identify Pouch of Douglas Malignancies

While many of these symptoms overlap with other issues that lay beyond the peritoneal cavity that are so common to women’s reproductive health, nonetheless, one should remain vigilant and question whether or not there is a need to have the pouch of Douglas examined.

Symptoms vary but include: 

  • Abdominal pain and distension
  • Abnormal uterine bleeding
  • Introitus lump
  • Reduced stool caliber

Too often, these symptoms are mistakenly attributed solely to pathologies of the uterus or ovaries due to their similarity in appearance via imaging technology. In many cases, examination of the rectouterine pouch is ignored in favor of searching for causality in these two most common offenders, glossing over potential complications specific to the peritoneal cavity.

What Malignancies Are Specific to the Pouch of Douglas?

Listed below are the three primary malignancies specific to the Pouch of Douglas, seen in both men and women. 

Mullerian Adenosarcomas: Extragenital 

The rarity of primary peritoneal cavity issues makes literature on the subject quite scarce, and this is partly why they are misdiagnosed based on ultrasound and MRI scans. Usually, they are unintentionally characterized as having a uterine or ovarian origin regarding legion metastases. In short, the result is that doctors may accidentally attribute the source to various forms of ovarian cancer. It is important to note that sometimes, these issues are concurrent. 

However, non-ovarian lesions have sparked intense study, relegated to the peritoneal cavity. Researcher Ker Yi Wong wrote about Mullerian adenosarcoma in their collaborative article surrounding the primary pouch of Douglas malignancies. They stated that malignant stromal (sarcomatous) and benign epithelial components, which typically arise from the uterus, make up the mixed neoplasms seen in Mullerian adenosarcoma. Location is vital in understanding their behavior regarding one’s health. 

While uterine adenosarcomas have great prognosis, extragenital adenosarcomas typically have higher rates of occurring more than once and mortality in comparison. Unfortunately, these pouch of Douglas lesions are rare enough that, at this point in time, there is no agreement yet on the best treatment for them. Surgery and chemotherapy have been endorsed, with about a 50% effectiveness rate.

Pouch of Douglas Hernias

A hernia occurs when fatty tissue or an organ, like the intestines, slips through a spot in the weakened connective tissue or muscle surrounding it. In accordance with documentation by doctors John Bunni and James Berstock in the attached article, it is understood that peritoneal cavity hernias are an unusual form of pelvic hernia that appears to manifest predominantly in elderly, multiparous women, as well as those who have undergone previous pelvic surgery in their lifetime.

Hernias of the rectouterine pouch are classified as perineal hernias and are very rare. It is generally accepted that pelvic hernias as a unit are not at all commonplace, so treatment of them is somewhat obscure and still in its nascent stages. Surgery is presented as the best option, as is the resolution for the patient featured in the case study presented in detail upon which the article is founded.

Men vs. the Pouch of Douglas

The discussion thus far on the cul-de-sac has centered on its implications for women’s reproductive health and the potential threats to this region pathologically, due to its proximity to the uterus and ovaries. Males also possess this anatomical space dubbed the rectovesical pouch.

The lowest part of the peritoneal cavity is known as the rectovesical pouch. It typically has loops of the sigmoid colon or the small bowel. It is a space for potential fluids to collect in males due to its close relation to the anal margins. It is directly analogous to the rectouterine pouch in females and is otherwise still collectively known as the pouch of Douglas.

Just as it can cause problems in women, men are not immune to the consequences of amassing materials in the peritoneal cavity due to its location. It is a receptacle for extraneous fluids, puss, and even blood, and an infection in this area may pose significant harm to the rectum and prostate of the one affected.

Being informed can allow an individual to take precautions to maintain their longevity. Though it is often overlooked by doctors searching for causality regarding lower abdominal abnormalities, here is a short list of associated pathologies of the rectovesical pouch.

Related Pathologies 

  • Ascites (hydroperitoneum): an abnormal amount of intraperitoneal fluid in the peritoneal cavity. 
  • Haemoperitoneum: the presence and accumulation of blood within the peritoneal cavity. 

Frequently Asked Questions

What is the pouch of Douglas?

The pouch of Douglas is a small hollow located in the pelvic region of the human body. It is a potential space between the uterus's back wall and the rectum's anterior wall. It is also known as the rectouterine pouch or the cul-de-sac. It is an important structure in women’s reproductive health and is used in gynecological examinations.

What is the purpose of the pouch of Douglas?

The pouch of Douglas serves several purposes. It is used as a guide for gynecological examinations, and it is also used to identify and diagnose diseases of the reproductive organs. Additionally, it is essential to move the organs in the pelvic cavity. It also acts as a barrier between the uterus and rectum, which helps to keep the organs separate and prevent contamination.

What are the risks associated with the pouch of Douglas?

The pouch of Douglas is associated with a few risks. It can become inflamed or infected, leading to pain and discomfort. Additionally, there is a risk of developing a hernia in the pouch, which can cause severe pain and discomfort. Surgery may be necessary to correct the hernia.

How is the pouch of Douglas diagnosed?

The pouch of Douglas is typically diagnosed through an abdominal or pelvic examination. The doctor will examine the pelvic area during the exam to check for abnormalities or signs of infection or inflammation. Additionally, imaging tests such as an ultrasound or CT scan may be used to diagnose the pouch.

The Health Board is dedicated to providing accurate and trustworthy information. We carefully select reputable sources and employ a rigorous fact-checking process to maintain the highest standards. To learn more about our commitment to accuracy, read our editorial process.
Mary McMahon
By Mary McMahon

Ever since she began contributing to the site several years ago, Mary has embraced the exciting challenge of being a The Health Board researcher and writer. Mary has a liberal arts degree from Goddard College and spends her free time reading, cooking, and exploring the great outdoors.

Discussion Comments

By anon976981 — On Nov 07, 2014

My daughter was diagnosed with PID - Pelvic Inflammatory Disease after an ultrasound was done on her. She has a normal sized non-gravid uterus and collection of fluid in pouch of Douglas?

By anon352818 — On Oct 25, 2013

I have seen only minimal fluid in the pouch and one tube is blocked after an SSG test. Can someone let me know what are the chances I can get pregnant?

By vennila — On Nov 30, 2012

My sister-in-law has undergone tests for the pouch of Douglas. In that report, they have mentioned not free of fluid in the pouch of Douglas. What does that mean? She is 23 and hasn't been pregnant. Can anyone clarify?

By anon295932 — On Oct 09, 2012

I have a complex cyst in my right ovary and minimal free fluid is also present in the pouch of Douglas. During periods my lower abdomen hurts a lot, especially the left part and it lasts for a long time. I also vomit a lot during this time. Please suggest something.

By anon175879 — On May 13, 2011

I have just been told that i have fluid in my pouch of douglas, but my doctor has said that there is nothing i can do about it. it causes a lot of pain and is extremely uncomfortable down there! i would like to know if i should get a second opinion?

By anon166369 — On Apr 08, 2011

I have just been told that I have a cyst in the Pouch of Douglas. What does this mean?

By anon145044 — On Jan 21, 2011

i have been scanned many times and was told i have fluid in my cul de sac. i have taken many medications but the fluid is only reduced. what do i do?

By anon127473 — On Nov 16, 2010

After my laparoscopy yesterday I was told I have quite extensive endometriosis, including in a type of "pocket" area behind the womb and I'm wondering if this is the Pouch of Douglas? If anyone has any info which would be helpful, I'd be grateful to hear it.

By pharmchick78 — On Aug 05, 2010

@CopperPipe -- You're right, a collapsed cyst can be a cause of fluid in the pouch of Douglas.

Other potential causes include endometriosis, although more than fluid in the area is needed for a diagnosis of endometriosis.

Finally, fluid in the pouch of Douglas can also occur after ovulation as just a normal part of the menstrual cycle.

If you have any pain in the area, or suspect that you may have fluid in your pouch of Douglas, you should consult your doctor, just in case.

Better safe than sorry!

By CopperPipe — On Aug 05, 2010

What can be some causes of free fluid in the pouch of Douglas?

I've heard that it can be the sign of a cyst that has collapsed, but wasn't sure.

Does anybody know?

By pharmchick78 — On Aug 05, 2010

It is important to differentiate between the pouch of Douglas and the pouch of Morrison.

While the one is in the peritoneal cavity, the other (Morrison's) is between the liver and the right kidney.

This pouch can also fill with fluid and become infected, just like the pouch of Douglas, and in some cases can require urgent surgery for endometriosis.

Mary McMahon

Mary McMahon

Ever since she began contributing to the site several years ago, Mary has embraced the exciting challenge of being a...

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