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Rectouterine Pouch (Pouch of Douglas)

excavatio rectouterina (Douglas)

The rectouterine pouch (pouch of Douglas, cul-de-sac) is the most dependent peritoneal recess in the upright female pelvis, located between the posterior surface of the uterus and cervix anteriorly and the anterior surface of the rectum posteriorly. It is bounded laterally by the uterosacral ligaments. In males, the equivalent rectovesical pouch lies between the bladder and the rectum. Free fluid in the pelvis preferentially collects in this lowest peritoneal space.

Region: Pelvis & Hip

Clinical Relevance

Clinical Notes

The rectouterine pouch is clinically relevant in several conditions: culdocentesis (aspiration of fluid from the pouch through the posterior vaginal fornix) diagnoses haemoperitoneum from ectopic pregnancy or ovarian cyst rupture; deep infiltrating endometriosis most commonly affects this pouch and the uterosacral ligaments; ovarian cancer peritoneal deposits in the pouch of Douglas produce the Blumer's shelf sign on rectal examination (palpable tumour deposits in the anterior rectum from peritoneal seeding); and pelvic abscess from ruptured appendix or diverticulitis tracks to this dependent pouch.

Pathology

Common Injuries & Conditions

Endometriosis in the Pouch of Douglas with Uterosacral Involvement

Deep infiltrating endometriosis most commonly involves the posterior cul-de-sac (pouch of Douglas), uterosacral ligaments, and anterior rectal wall, producing severe dysmenorrhoea, deep dyspareunia, and dyschezia; MRI delineates the depth of rectal wall infiltration and laparoscopic excision of the endometriotic nodule with rectal shaving or disc excision is required for complete pain relief.