The cul-de-sac of Douglas, or rectouterine excavation, is a region close to the cervix that corresponds to the lowest part of the peritoneal cavity, which is formed by the tissue that covers the entire internal part of the abdomen and its organs.
Due to its location, this is usually the first place where fluid accumulation in the abdomen can be identified, which may indicate health problems such as infections, rupture of an ovarian cyst and, although rare, metastases of a tumor.
If you suspect changes in the cul-de-sac of Douglas during an examination, it is recommended to consult a gynecologist or the doctor who indicated it to evaluate the result and check if there is any health problem that requires treatment.
What is it for
The Douglas cul-de-sac is used to:
- Check for fluid accumulation inside the abdomen through imaging testssuch as ultrasound or magnetic resonance imaging;
- Perform peritoneal dialysisin case of severe chronic kidney disease;
- Perform the puncture to collect eggswhen in vitro fertilization will be performed;
- Collect a liquid sample for analysiswhich may be indicated in some cases to identify the cause of its accumulation in the abdomen;
Furthermore, the gynecologist usually evaluates this region indirectly through vaginal examination during a gynecological examination, and changes in its shape or sensitivity may be identified, indicative of problems such as endometriosis or infections.
Read too: Endometriosis: what it is, symptoms, causes and treatment
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Where is Douglas’s bag?
The bag of Douglas is a region between the uterus and the rectum, as shown in the following image:
What does free Douglas cul-de-sac mean?
A free cul-de-sac of Douglas on an exam usually means that no fluid has accumulated inside it.
Although the presence of fluid in the sac of Douglas is not always considered a serious problem, it may indicate infections or bleeding, for example.
Related diseases
Douglas’ cul-de-sac can be affected by diseases such as endometriosis, ectopic pregnancy, especially after in vitro fertilization, ascites, which is the accumulation of fluid in the abdomen, infections, some types of hernia and, although rare, cancer.
Read too: Ascites: what it is, symptoms, causes and treatment
Although it is also rare, Douglas cul-de-sac rupture can happen in some women during sexual intercourse, especially when the relationship is not consensual.
What can be liquid in the sac of Douglas?
Fluid in the sac of Douglas can be caused by:
- Ovulationdue to the rupture of an ovarian follicle;
- Pelvic inflammatory diseasewhich can result in the formation of pus;
- Tuberculose peritonealwhich is when the bacteria settles in the abdomen;
- Rupture of an ovarian cystleading to the exit of fluid from its interior;
- Ectopic pregnancyin case of bleeding due to its rupture;
- Vessel bleedingwhich can happen after sexual intercourse, although rare;
- Cancerin case of metastases.
Although it does not always have a specific meaning, fluid in the sac of Douglas may indicate blood, pus, or fluid accumulation.
Therefore, it is important to consult a gynecologist if it is identified to see if it could indicate a health problem.
Ruptured sac of Douglas
Rupture of the Douglas sac is rare and can be caused by trauma, such as accidents, falls, vaginal birth or intense, violent or non-consensual sexual intercourse, for example.
Additionally, although it is rarer, it can also be caused by gynecological surgical procedures.
Rupture of the sac of Douglas can cause hemorrhage and intense vaginal bleeding, as it is a region that has many blood vessels.
Therefore, in the case of suspected rupture of the sac of Douglas, you must go to the hospital immediately so that the most appropriate treatment can be initiated, which is normally done with surgery, to avoid complications, such as hypovolemic shock or cardiorespiratory arrest.
Bibliography
- HELLER, Debra S. Lesions of the Pouch of Douglas: A Review. J Minim Invasive Gynecol. Vol.23, n.1. 28-33, 2016
- SALT. I. et al. The “pouch” of the Douglas’s pouch. Morphology. Vol.101, n.333. 105-109, 2017
- RADIOPAEDIA. Rectouterine pouch. 2023. Available at: <https://radiopaedia.org/articles/rectouterine-pouch>. Accessed on 06 Feb 2024
- RADIOPAEDIA. Differential diagnosis of free fluid in cul de sac (pouch of Douglas). 2019. Available at: <https://radiopaedia.org/articles/differential-diagnosis-of-free-fluid-in-cul-de-sac-pouch-of-douglas>. Accessed on 06 Feb 2024
- Wong, Ker Y. et al. Primary Pouch of Douglas malignancies: A case series and review of the literature. Gynecol Oncol Rep. Vol.21. 94–97, 2017
