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Pouch of Douglas

excavatio rectouterina

The pouch of Douglas (rectouterine pouch, cul-de-sac) is the most inferior and most dependent part of the peritoneal cavity in the supine female pelvis, lying between the posterior uterus and the anterior rectal wall. In males, the rectovesical pouch lies between the bladder and rectum. Free peritoneal fluid accumulates here first in the supine position. The peritoneum of Douglas pouch directly overlies the posterior vaginal fornix.

Region: Pelvis & Hip

Clinical Relevance

Clinical Notes

The pouch of Douglas is clinically accessed by culdocentesis (needle through the posterior vaginal fornix into the cul-de-sac) to diagnose haemoperitoneum from ectopic pregnancy rupture, pelvic inflammatory disease, or cul-de-sac abscess. Endometriosis deposits preferentially in the pouch of Douglas, producing deep infiltrating endometriosis of the rectouterine space, rectovaginal septum, and uterosacral ligaments. Ovarian cancer implants extensively in the cul-de-sac (omental cake and cul-de-sac disease in advanced ovarian cancer). Culdoscopy (endoscopy through the posterior fornix) was an early gynaecological approach.

Pathology

Common Injuries & Conditions

Deep Infiltrating Endometriosis of the Pouch of Douglas

Endometriosis infiltrating the pouch of Douglas involves the rectouterine peritoneum, posterior cervix, uterosacral ligaments, and rectovaginal septum, producing severe dysmenorrhoea and dyspareunia; complete excision requires bowel preparation and may necessitate discoid resection or rectal shave to achieve complete excision.