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.
| Location | Female pelvis, between the uterus and the rectum |
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The lowest point of the peritoneal cavity in women, so fluid, blood and pus collect here. It can be reached through the posterior vaginal fornix and is a common site of endometriosis.
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.
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.
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