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

Inflammatory process in any of the pelvic organ may cause oozing out of fluid. This fluid may get collected in the pouch of douglas.

Pelvic Inflammatory Disease

This is a broad term that include all infections of the upper female genital tract. Most often, the infections ascend form the cervix or the vagina.

The causative micro- organism climbs up the vagina to enter the uterus, then the tubes an finally the ovaries.

Sometimes, there may be an infection in the appendix or nearby intestines. In such situations, the ovaries or the tubes may get infected directly from these infected organs.

PID presents itself clinically as low abdomen pain with backache. There may be fever, an increase in the total white blood cells of the body.

There may or may not be a discharge from the vagina.

Your doctor may examine you well and order a couple of test, including cervical swab, to make the diagnosis.

Most cases of PID would have some fluid collected in the pouch of douglas.

Treatment is treating the infection with the help of appropriate antibiotics. The fluid is absorbed back with time.

Tubo Ovarian Abscess

Following PID or cases of T.B., pus may get collected in the Fallopian tubes. There is pain in the lower abdomen of the affected side.

The patient may have pain, fever, nausea and an increased TLC.

Inflamed tube oozes out fluid that gets collected in the pouch of douglas.

Hydatidiform Mole

This is a condition in which an abnormal growth occupies the uterus, rarely the tube. The structure may or may not accompany a fetus.

Inflammatory process occurs and fluid may be seen in the pouch of douglas.

Ectopic Pregnancy

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.

Endometriosis

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.

Apart from heavy bleeds every month, dyspareunia is another common symptom of having endometriosis in the pouch of douglas itself. This means having pain during intercourse.

Peritonitis

Inflammation of the peritoneum due to any increase may cause it to ooze out fluid, which may get collected in the cul de sac.

Ruptured Ovarian Cyst

Cyst formation occurs in the follicles of the ovaries during reproductive ages. Any cyst, which has grown big in size, may rupture spontaneously. Fluid may get collected in the pouch.

Medical Advice (Q&As) on “Causes of Having Fluid in the Pouch of Douglas

  1. Sylvia

    Pls there seems to be a hard lump on my cervix and another just at the tip of my cervix. It is slightly painful to the touch. I have the urge to urinate frequently sometimes with a burning sensation. I feel severe pain s in my lower abdomen, lower back, my two ovary sides and the worst is I feel a movement in my lower abdomen especially when I run. I had an ultrasound scan today and it said “fluid collection seen in Pouch of Douglas”
    What could it be?
    Is there anything to worry about?

    Reply
    1. Yinka

      I’m 30. I have having irregular period and diagnosed for PID which I have been on antiobiotics. I had pelvic scan and the result shows-
      that the uterus is pear shape anteverted and normal in size for nuliparous
      It measures about 39mm*32mm*33mm L*W*AP diameters
      The outline is smooth with homogeneous echopattern
      The endometrium is thin and hyperechoic
      No intra and/or extra uterine gestational sac seen
      No myoma is noted
      Pouch of Douglas consist of fluid collection.
      Pls can you explain this result to me and will the fluid in the POD not hinder me from conceiving.

      Reply
      1. Buddy M.D. Post author

        Fluid gets collected in the pouch when you have an infection.

        As you take antibiotics, your infection would heal up and the fluid would also dry up. Once complete treatment has been taken, pregnancy is likely to be safe.

        Reply
  2. Sammy

    So I went to the gyno today because Ive had normal periods but in between periods I had very dark brown/black slimy discharge (lasting 5 days at a time and very heavy, like a second period but much darker nad thicker consistency) and cramping no matter if i have my period or not.this has been going on for 3 month now. My Gyno did a vaginal ultrasound and took a little swab to send to the lab. I haven’t had intercourse in over 6 month, and have a history of endometriosis. but she said it was not that. she did see fluid in my pelvis area, I assume in the pouch of Douglas. I am wondering should I go see my generalist as well to get blood work done (iron-deficiency because of heavy period?) might I have something more concerning that can not be detected with a quick vaginal ultrasound and a little swab? ive got cancer issues in my family (colon, intestine).
    trying to not be paranoid but ebut im a little worried it might be something to investigate further.

    Reply
    1. Buddy M.D. Post author

      Unlikely to be malignancy.

      There appears to be some issue in your uterus. If it’s not endometriosis, may be you have a fibroid or some other problem in the uterus. Your gyne would be able to find that out.

      However, it’s not a bad idea to see a generalist to correct anemia. You are very likely to be having that.

      Reply
  3. margaret

    I have pain in my lower abdomen,i did an ultrasound 2yrs back saying mildfluid in pod n submucosocal fibroid 24mm*26mm,was prescribed antibiotics but I haven’t conceived what could be d problem.

    Reply
    1. Buddy M.D. Post author

      To assess fertility, you need to be thoroughly examined by a gyne. There are many factors that may be contributing to difficulty in conception.

      Your hormonal levels, condition of tubes, present size of the fibroid, need to be checked.

      Mild fluid in POD is likely to have been resolved by the antibiotic course. The small fibroid may have grown in size. It’s location is also important. Where exactly in the uterus is it located?

      A big sized fibroid or fibroids interfering with common sites of conception may make it difficult for the egg to implant.

      Reply
  4. Fiza

    I hve pain in lower abdomen so i got ultrasound n cme 2 knew hvng fluid pouches douglas.by it im not getting periods regularly n getting weight aftr doing walking n diet.can u advise me wht 2 do 2 cure this.i heard dat cant get pragnancy too

    Reply
    1. Buddy M.D. Post author

      Can you let us know the full ultrasound report? Any cyst in the ovaries? What medication were you given?

      Reply
  5. Busayo

    My menses flow for just two days and no drop the third day while on fourth day few drops. The quantity starts decreasing right from the first day. I started noticing this from 2009. Recently I was diagnosed for having mild fluid in the pouch of Douglas and questionable pid. I urinate often Doctor did scan for me and said my endometrial isn’t smooth. Is there a cure for this and can i still have a regular menses

    Reply
    1. Buddy M.D. Post author

      Your age?

      You may be having some hormonal problem, giving you a rough endometrium as well, that’s interfering with proper menses. You need to see a gyne for full evaluation.

      Reply
  6. Busayo

    I’ll be 30,I do experience itching too, abdominal pain, irregular menses, and sometimes I bloat from the vaginal. I have used clotrimazole insertion several times but no difference. I was diagnosed of mild fluid in the pouch of Douglas and questionable pelvic inflammatory disease

    Reply
    1. Buddy M.D. Post author

      You need to go for an ultrasound lower abdomen, to assess the condition of the ovaries.

      PID would require a course of antibiotics to go.

      Reply
  7. Dora

    Obscuring bowel gas is noted in the lower abdomen. A small amount of fluid, within Normal limits, is seen in pouch of Douglas. Incidentally, an extrarenal pelvis is noted on the right side. What is wrong with me? Am I running any risk? Thanks for answering my questions.

    Reply
  8. ruth

    My menses flow rounds up at the, fourth day, bled on the 6th day during sex, I hope there is no problem.

    Reply
  9. Vivianne

    I have a problem i went for ultrasound and found that I have a mild fluid in Douglas pouch and am on medication may this cause me not to conceive

    Reply
  10. RR

    I have severe backache during periods which increased over and above the usual pain. Continuous bleeding starts after sighting clots for 3-4 days though periods is regular every 28 days and have never missed periods. Went to gynecologist and did scan result of which is fluid in pouch of Douglas and to consider PCOD. I have never had PCOD and mother of two never missed my periods. So how is PCOD possible and how to treat the fluid accumulation

    Reply
    1. Buddy M.D. Post author

      PCOD patients usually have some menstrual irregularity, excess hair growth, acne, and obesity. Do you have any of them? Did they check your hormonal levels?

      Reply
  11. Ashneer

    What causes fluid in pod? If it’s infection then can’t it be treated at home ? I mean by home remedy ?
    Recently I did my ultrasound n minimal fluid in pod is observed … n recently I experienced pain in right part of lower abdomen .. plz suggest something

    Reply
    1. Buddy M.D. Post author

      This indicates an infection somewhere in your pelvic organs. It’s strongly suggested that you take antibiotics for this. Don’t delay. This would only given the infection a chance to spread.

      Reply
  12. Muriel

    Hello I am 37 year old with a history of uterine fibroids. I also had a myomectomy about 5 years ago .I had unexplained infertility and after a failed IVF treatment I got pregnant and miscarried at 7 weeks and now have a 15month old who was born at 30 weeks gestation . For the past 4 months I experience pain outside of my menstrual cycle and have had in between bleeding for the last 2 months . My recent ultra sound scan shows a large fibroid occupying the whole pouch of Douglas .I was told that fibroids don’t cause bleeding in between periods ( although I am not convinced this is so ). I am in constant pain and have been given no explanation or reason for my constant pain . I was given Esmya 5mg tablets to start on for 3 months to help shrink the fibroids which I haven’t taken due to the long list of side effects and I’m breast feeding in addition to the fact that I was not given an explanation as to what is causing my pain and bleeding which is what worries me more than the fibroids . Is there any thing more I can get done to get to the bottom of this .

    Reply
    1. Buddy M.D. Post author

      Something needs to be done about that big fibroid. If you can’t go for the pills, you’ll need a surgical resection. Blood loss this way cannot be afforded.

      Reply
      1. Muriel

        Thank you for your response . I was given the option to try for a second pregnancy as well . I don’t know if that a good idea. As the poll would definitely be out of question in pregnancy .

        Reply
        1. Buddy M.D. Post author

          You need complete treatment first. This may take time, around a year or two. It’s better not be go for conception before that.

          Reply
  13. Yinka

    I’m 30. I have having irregular period and diagnosed for PID which I have been on antiobiotics. I had pelvic scan and the result shows-
    that the uterus is pear shape anteverted and normal in size for nuliparous
    It measures about 39mm*32mm*33mm L*W*AP diameters
    The outline is smooth with homogeneous echopattern
    The endometrium is thin and hyperechoic
    No intra and/or extra uterine gestational sac seen
    No myoma is noted
    Pouch of Douglas consist of fluid collection.
    Pls can you explain this result to me and will the fluid in the POD not hinder me from conceiving.

    Reply
  14. Elizabeth

    Uterus Normal 6.5 cm in greatest span , endometrial strip 6.3mm No fluid , No focal abnormalities, normal ovary size, Fluid in Cul -de- Sac … Should I worry ? Dr. Advised no treatment … Should I seek a 2nd opinion.

    Reply
      1. Elizabeth

        I had Experienced A-sharp pain and got a tranvaginal ultrasound. The doctor reviewed the images and said it was nothing to worry about… no treatment needed . That I was good to have children any day…. she just said a string of pearls … that it was not a concern to the point for treatment or infertility issues .

        Reply
  15. Gloria

    I went for an ultra sound scan and I was told I have free fluid in the pouch of Douglas, and I was started on antibiotics. But during the last days of the dose, my lower abdomen is always extending after I have eaten food and I also have vaginal discharges that are mucoid.

    What may be the problem?

    Reply
  16. Ayomide

    Am 33Years, I went for scan my uterus is very bulky and anteverted in shape, with heterogeneous echo pattern and measures about 104mm*64mm*63mm in length, width and AP diameter. The endometrial plate is not visible.
    Palpable mass noted within uterus, no adnexae mass noted. Moderate free fluid found in the POD.
    Impression intrauterine myoma (ii) PID pls what antibiotics can I take to cure this? I want to conceive.

    Reply
    1. Buddy M.D. Post author

      You’ll be given antibiotics to treat PID. Apart from this, your doctor may suggest going for a DnC. This is a small operative procedure, which would scrape off the myoma.

      Reply
  17. Retha

    I got spontaneous complete abortion on 2 of this month and I m still bleeding, Though got trapic tab and pause injection even today. I’m still bleeding. Scan report says minimal fluid in pouch of Douglas. And a small cyst left ovary. Please let me know why.

    Reply
    1. Buddy M.D. Post author

      It is common to bleed for a few days consequent to spontaneous abortions.

      However, if you bleed heavy, you need to see your doctor. The dose of medicines being given may be adjusted.

      What was the reason for abortion?

      Reply
  18. Tammy

    Had LSH 7 days ago, fibroids were causing abdominal pressure, pressing into my back on the right side and a lot of other things.
    Three days ago I began to have low back pain to the point I had to take medicine for it.. Would like to know if the pouch of Douglas would have anything to do with this.. I’m mobile not doing too much just a little at a time but the back pain is lingering around..

    Reply
  19. Tammy

    No bleeding and the back pain has pretty much subsided. I’m just trying to get my gait back since I don’t have the pressure and abdominal bulging anymore, i looked 4-5 months pregnant. I’m adjusting..

    Reply
    1. Buddy M.D. Post author

      Just give it time. Your ligaments might by pulling and giving you the pain, as they adjust themselves in the new space provided.

      A heating pad may be used to alleviate pain. However, do not over use.

      Reply
  20. Faith

    How long does it take fluid in the pouch of Douglas to go away and please I would love to know the type of antibiotics to use. Thanks for your response.

    Reply
    1. Buddy M.D. Post author

      10 to 15 days, approximately. The fluid gradually reduces in amount as your infection gets treated.

      Reply
  21. Victoria

    Am a lady of 30yrs, started having severe lower abdominal pain which radiates to the back and burning sensation, chills even when the weather is hot, temp BTW 36 -370c, no vagina discharge, nausea /vomiting, loss of appetite, bloating, breast tenderness, dizziness and feeling of fainting, all this started on June. I thought it was pregnancy because I have been trying to conceive after my wedding on March this Year, I had pelvic scan which shows Non gravid anteverted uterus measures 71 mm45 me, 55mm in long, Ap diameter $ transverse diameter. Normal endometrial echo is homogeneous and no sign of fibroid mass seen, both adnexa are free. Urinary bladder wall is normal with clear contents. MILD FLUID COLLECTION in the POUCH OF DOUGLAS, I was given Iv ceftrixone for 2days, levofloxacin 1dly for 10days, azithromycin 1g start then 250mg for 2days, flagyl 400mg for 7days, diclofenac 50mg 2times dly. I took on June when I had the symptoms, had normal 4days menses in a 28days cycle , but this July my menses lasted for just 2days in a 30days cycle still presenting with the same symptoms, carried another scan still the same result but very mild fluid collection. Please, what do I do to tackle this as I want to be pregnant soon, and how long will it take to conceive?

    Reply
    1. Buddy M.D. Post author

      Fluid in pouch of douglas indicates the presence of an infection there. It’s very important to treat it before you conceive.

      You have already taken antibiotics for around 10 days. May be your doctor gives you more of these pills.

      Fluid collected there may take time to resolve. However, you should be free from your symptoms. Any fever, chills or pain would mean you still have the infection.

      Reply
  22. Margaret

    Very few weeks pregnant, pelvic scan just indicated mild fluid in the pouch of Douglas? Haven’t read some of your responses above, I already know it’s an infection, but what should I rather do or what is your medical advise? I patiently await your response. Thank you.

    Reply
    1. Buddy M.D. Post author

      Your gyne is the best person to answer this. She’ll examine you to see if you have any symptoms of infection. If not, no treatment is required. Medicines, in early pregnancy, may harm the baby.

      Only if there’s fulminant infection, you’ll need treatment.

      The baby is securely packed inside the uterus, so don’t worry, he’ll not be affected by minor problems going outside.

      Reply
  23. Aderonke

    I did for scan 6/7/2017 because I was having this feeling that am pregnant but my scan result said this: ( A non gravid, anteverted , normal sized uterus measuring about 62mm x 44mm x 48mm ( longitudinal x Ap x transerve ) with myometrial echo texture. Uterine outline is consistent and of border regularity. Endometrial plate is thickened. No intra or extra uterine gestation seen. No evidence of retained product of conception. Within the cul- de- sac, indicative of pelvic inflammatory disease. Adnexae are relatively free. No obvious gross ovarian lesion noted. Both ovaries are normal in size, shape and echo texture) please what those this means.

    Reply
        1. Buddy M.D. Post author

          You may be having a condition called Endometriosis. Further investigations are required for diagnosis. Your doctor may suggest laproscopy.

          You may be having any menstrual abnormalities?

          Reply
  24. Biodun Ariyo

    Good day,
    I did a pelvic scan and the result shows that the pouch of Douglas contains marked fluid collection….

    What should I do next.

    Reply
    1. Buddy M.D. Post author

      In general, fluid collected in this pouch suggests some infection in the pelvic area. However, there are other conditions too, where fluid may get collected in the pouch.

      Your clinical symptoms need to be correlated to reach a diagnosis.

      Reply
  25. LKD

    I am 49 and have had sciatic- like pain on right side that can radiate down to calf and pain at lateral edge of right sacrum for 2 1/2 years. Pain is usually worse before and during period. No previous history or endometriosis. Lumbar MRI negative. I had a pelvic MRI a year ago and radiologist indicated there was fluid in the cul de sac, most likely from a rupturned cyst. A few months later I was diagnosed with piriformis syndrome and received treatment which gave me little relief. One year later I had a 2nd MRI and same area is showing up and looks exactly the same as what was diagnosed as fluid. Is it possible for fluid in the cul de sac to remain there for a year?? I find it more likely that it was not fluid to begin with and may be something else. I have no abdominal or pelvic pain. I have no indication of an infection…. just sciatic pain and gluteal pain along the lateral right side of sacrum.

    Reply
    1. Buddy M.D. Post author

      It’s essential that you get your female parts examined by a gyne. Just a routine check up at the age of 49. This should include an internal exam, pap smear. Ultrasounds are already done.

      Looks like we are missing something.

      Reply
      1. Lkd

        Thanks! I have had my annual PAP and my GYNO is aware of the situation, she ordered the ultrasound. Just wondered if you may have any other suggestions.

        Reply
  26. Rabbi

    I have been having lower abdominal pain, pain during sex, and whenever I have sex with my partner the semen leaks and I have been finding it difficult to get pregnant and my menses last for three days but the dates always change.
    I went for a gynecological scan and was told I have normal uterus but some fluid found in the pouch of Douglas. Please I want to know what the problem is, but my doctor prescribed cefuroxime 500mg for me.

    Reply
    1. Buddy M.D. Post author

      You may take this antibiotic as prescribed. Also, an ultrasound lower abdomen needs to be done to rule out any chances of endometiosis or any other condition.

      Reply
  27. sarah

    Pelvic ultrasound reads:
    the uterus appears bulky in size, hypoehoic and heterogeneous in appearance large ill-defined calcified sub serosa fibroid with irregular borders extending upward towards the lower abdominal cavity measuring (97.1×99.0)mm in diameter. No pregnancy detected on ultrasound imaging. Pouch of Douglas seen with free fluid. Both ovaries were not visible due to enlargement of uterine fibroid growing within and outside the uterine walls. The endometrial echo was absent. There was volume of dilated serous fluid collection seen within the recto uterine cavity. Please this is the ultrasound results. I only have lower abdominal before and during menstrual period and I never hospitalized or treated PID before.

    Reply