Pouch of Douglas
Pouch of Douglas is a peritoneal fold present behind the uterus. It lies between the uterus and the rectum. It is present only in females.
How is it formed?
All our visceral organs are carefully packed inside and covered by a membranous layer, called the peritoneum. As this membranes covers the internal organs of the body, it may form folds as it spread.
One such fold is the pouch of douglas, which is formed when the peritoneum covers the uterus and then climbs upwards to cover the rectum behind.
Pouch of douglas is also called cul de sac. This area is the bottom most portion of the peritoneal cavity, therefore, when any fluid oozes in the peritoneal cavity, it tends to get accumulated here.
Causes of Fluid in the Pouch of Douglas
Any cause of inflammation in one or more pelvic organs may lead to oozing of inflammatory fluid from it. This fluid may get collected in the pouch of douglas.
Below are listed the common conditions that cause it-
Pelvic Inflammatory Disease
This is the commonest cause of having fluid in POD. So, it’s important to get investigated and rule out the possibility of having PID.
What is PID?
This is a broad term used for any infection in the female reproductive tract. Commonly, the cervix, uterus or the fallopian tubes get infected.
The commonest infections causing it are chlamydia and gonorrhea. However, after childbirth, miscarriages, or any procedural instrumentation done over the uterus, the pelvic organs may get infected by many more bacteria residing in the vagina.
What Makes You Prone to Get PID After Procedures Done in the Vaginal Canal?
Normally, the cervix creates thick mucoid layer that serves as a protection for inner organs, not letting any bacteria or other organisms climb in. However, during any procedures done lower down, this barrier breaks up, allowing easy access for bugs to climb up and infect pelvic organs.
- A dull, but constant, pain down there. This may be there for weeks before you finally note it.
- Discharge from the vaginal canal may be there in some cases. This may be scanty to profuse. It may look like a menstrual bleed that’s more dirty brown and always foul smelling.
- Pain and burning during urination.
- Pain during sex. You may also bleed after sexual activities.
- Low back ache is very common.
- In severe cases, fever, with or without chills.
- Abnormal uterine bleeding in between menses or after sex.
- Increased levels of total white blood cell counts.
Your doctor may examine you well and order a couple of test, including cervical swab, to make the diagnosis.
- Fluid present in Pouch of Douglas
- Organs may show no change in early stages. Later stages, there may be an adnexal mass, involving the ovary and tube, which are often indistinguishable due to inflammatory changes.
- In chronic cases, there maybe thickening of various ligaments holding the uterus.
Treatment is treating the infection with the help of appropriate antibiotics. It usually takes a long course of combination pills of the infection to resolve. The fluid in POD is absorbed back on its own with time.
Tubo Ovarian Abscess
Abscess is essentially a collection of pus. Following PID or chronic infections like Tuberculosis, a pus pocket may get formed in the Fallopian tubes.
There is pain in the lower abdomen of the affected side. The patient may have pain, fever, nausea and blood work may show an increased TLC .
Inflamed tube oozes out fluid that gets collected in the pouch of douglas. This may show up in ultrasound.
This is a condition in which a mass consisting of many fluid filled cyst like pockets occupies the uterus, or rarely the tube. The structure may or may not accompany a fetus.
It is formed when after fertilization of the egg, proper implantation and placenta formation is not seen. Instead of placental tissue, we see abnormal cysts developing around the fertilized egg.
Since the structure is not normal, an inflammatory response is triggered against it. Inflammatory fluid oozes out and may be seen in the pouch of douglas.
Implantation of a fertilized ovum anywhere else than the normal uterine cavity may be termed as ectopic pregnancy.
The commonest location is the Fallopian tube.
Here, the uterine lining that gives menstrual flow every month, may be present else where than the uterine cavity. This abnormally placed lining also bleeds when the women menstruates. Some blood may get collected in the cul de sac.
Endometriosis may occur in the pouch of douglas itself. In such conditions, apart from heavy bleeds every month, dyspareunia, that is, pain during sexual activity, is another common symptom.
Inflammation of the peritoneum due to any underlying disease may cause it to ooze out fluid, which may get collected in the cul de sac.
Ruptured Ovarian Cyst
It is common for cysts to get formed in the follicles of the ovaries during reproductive ages. Any such cyst, which has grown big in size, may rupture spontaneously. Fluid may get collected in the pouch.