Reproductive system · Pelvis · Female

Rectouterine pouch !

The rectouterine pouch (of Douglas) is the space between the uterus and the rectum, the lowest point of the abdomen; fluid or blood collects here first.

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What it is

The pocket of peritoneum between the back of the uterus and the rectum (pouch of Douglas), the lowest point of the abdominal cavity when standing.

What it does

Fluid or blood collects here first, so it is checked on ultrasound; a common site of endometriosis.

Key facts

Where

Peritoneal recess between the posterior uterus/posterior fornix and the rectum, bounded laterally by the uterosacral folds

Function

Lowest point of the peritoneal cavity (upright): fluid, blood or pus collects here; reached through the posterior fornix; common site of endometriosis

Relations

In front

Back of the uterus and supravaginal cervix, and the peritoneum over the posterior vaginal fornix

Behind

Front of the middle third of the rectum

Lateral

Uterosacral folds raised by the uterosacral ligament; the ovaries and uterine tubes may drop into it

Below

Rectovaginal septum, between the vagina and the rectum

Contents

Normally loops of ileum or sigmoid colon; in disease, fluid, blood, pus, endometriosis or tumour deposits

How to find it

Transvaginal ultrasound shows it in the sagittal plane behind the uterus and above the posterior fornix. On rectal or vaginal examination its contents are felt through the front wall of the rectum or the posterior fornix.

Examination

• Douglas cry: sharp pain when the pouch is pressed through the posterior fornix or the rectum, suggesting blood or pus irritating the pelvic peritoneum

On imaging

On sagittal transvaginal ultrasound it lies behind the uterus. A small amount of clear fluid is normal; echogenic fluid or clot with a positive pregnancy test and no intrauterine pregnancy suggests a ruptured ectopic. In trauma, the pelvic FAST view checks it through a full bladder. Transvaginal ultrasound and MRI show deep endometriosis obliterating it.

Common problems

• Weakened supports allow prolapse.
• Endometriosis often grows on the uterosacral ligaments.

How it is diagnosed

Examination and ultrasound; seen directly in laparoscopy.

Treatment

• They are divided step by step in a hysterectomy.

Clinical notes

• Culdocentesis, a needle through the posterior fornix into the pouch, was used to find blood (for example from a ruptured ectopic pregnancy); ultrasound has largely replaced it
• Pelvic abscesses after appendicitis, pelvic inflammatory disease or surgery collect here and may be drained through the vagina or the rectum
• The pelvic view of the FAST scan looks for free fluid here in women and in the rectovesical pouch in men
• Peritoneal metastases deposited here form a shelf felt on rectal or vaginal examination (Blumer shelf)
• A deep pouch can herniate down into the rectovaginal septum as an enterocele, a form of posterior compartment prolapse

Related conditions

• Endometriosis
• Ovarian hyperstimulation syndrome

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Educational information, not medical advice. For any symptom, see a health professional.

Its names

Official Latin (TA2)

excavatio rectouterina TA2 3726

Official Spanish (DeCS)

Excavación rectouterina

English (TA2)

Rectouterine pouch

Also called

cavum Douglasi · pouch of Douglas

Related

• Vaginal fornix
• Rectum

Sources: Terminologia Anatomica (TA2); Anatomy, Abdomen and Pelvis: Female Pelvic Cavity; Anatomy, Abdomen and Pelvis, Peritoneum.

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Representative model, for educational purposes only.