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.

Signs

  • 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.

Ultrasound Findings

  • 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.

Hydatidiform Mole

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.

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.

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.

Peritonitis

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.

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

  1. Florence

    The scan revealed fluid in pouch of douglass suggestive of pid so the gyneacologist prescribed spardium doctor please will I be okay after I take the drug I want to conceive ad soon as possible

    Reply
  2. Lilian

    I did scan and it says a cystic mass lesion measuring 24 ×23 mm is seen in the right ovary and significant fluid collection is seen in the pouch of Douglas. Please what does this mean. Hope it will not stop me from being pregnant

    Reply
    1. Buddy M.D. Post author

      There are many conditions which may give such a picture on scanning. One such is PID, pelvic inflammatory disease. Conceiving with PID is usually not possible and so, doctors suggest prior treatment.

      You do get your menses on time? Any other complain, like pain in back, vaginal itch/ discharge etc.?

      Reply
      1. Lilian

        No pains in the back, no vaginal itch, no discharge just having pains at the right side of my stomach. Please which drugs should I should

        Reply
          1. Buddy M.D. Post author

            Could be an active infection. Your doctor may prescribe you appropriate antibiotics.

  3. May

    HI doctor I did a scan and my uterus was normal measuring about 7.3cm n 3.2cm but the pouch of douglas appeared irregular and hazy no detachable cyesis too.
    Can it stop one from getting pregnant and is it. Something to be scared of?

    Reply
  4. Tosin

    Hi doctor, I’ve been having this lower part of my abdomen paining me and when it pains, id want to defecate and sometimes vomit then I do see whitish discharge from my vagina too. I went to the clinic last week Tuesday (Nov 27th 2018) and had the scan and it was said that there are Collection of fluid in my P. O. D. And I’ve been given several injections and drugs too including a vagina cream to apply. But I’m still having slight pain in the lower part of my abdomen. What can I do?

    Reply
    1. Buddy M.D. Post author

      You’re likely to be having some infection in your pelvic area. Continue with the injections and medications prescribed. It may take time for the infection to go. Your symptoms would gradually heal up.

      Reply
  5. Shade

    Hi Dr, I went to the clinic and an ultrasound was done, Dr said my ovaries are enlarged due to presence of cysts, the left one measuring 48.5*32.6*48.6 and the right measuring 45.0*46.7*49.9. This test was done on day 2of my menstrual cycle, could it be enlarged due to menstruation? Or does this findings affect my chances of having a baby?.

    I also had hormonal profile test done on day 21 FSH 2.4,LH 1.3,testosterone 0.3,progestrone 8.9 oestrogen 92.0,prolactin 15.4.. Dr said the result is ok but the cysts what do you think? Is causing it

    Reply
    1. Buddy M.D. Post author

      You need to be put on a pill for hormonal correction. Conceiving would be difficult before treatment.

      Reply
        1. Buddy M.D. Post author

          Results show normal values of all hormones for the 21st day!

          However, cyst development in the ovaries are primarily due to hormonal fluctuations. It’s difficult to say in which part of the cycle do the fluctuate. This needs to be investigated.

          Reply
  6. Oluwatoyin

    Hello doctor,I started feeling pain in my pelvic area since last year and have taken some antibiotics ,but the symptoms persist and i decided to go for scan, the scan review :a bulky non gravid uterus 5.94cm×5.11cm in size seen with intramural myoma 1.90cm×2.78cm in size. No degenerative changes seen in the myoma. There is free fluid collection in the pouch of douglas. No uterine scar and no ovarian abnormalities found feature:acyesis, lecomyoma,pid

    Reply
    1. Buddy M.D. Post author

      You have to be carrying a big sized, benign (not cancerous) tumor in your uterus. This mass is occupying a lot of space available in the uterine cavity, giving you pelvic pain and may be a sagging down feel.

      Also, there’s some infection in the pelvic area, which needs treatment.

      Reply
  7. Anthonia Obioha

    Please doctor help me out with the interpretation of this scan test, I had it yesterday.

    Uterus: The uterus is bulky, anteverted an non gravid, it measures about 121mm×93mm×101mm longitudinal, So and transverse diameter respectively. It contains an isoechoic intramural fibroid mass measuring 67.3mm×62.7mm. No evidence of intra/extra uterine gestation.
    Both adnexae are free and appear sonographically normal in size contents and echogenicity.
    Insignificant fluid collection was noted at the POD

    Reply
  8. Anthonia Obioha

    Can I also presently conceive with this result? Because am not happy right now. Please I urgently need your response.

    Reply
    1. Buddy M.D. Post author

      You appearing to be having a small fibroid in your uterus. Do you have any pain, bleeding or other symptoms?

      This one is a small growth. Whether or not you can conceive would depend upon the exact position of the fibroid in the uterus. Fibroids occupying the same position as the implanted egg may pose a risk to conception. also, some fibroids grow with pregnancy hormones while others don’t. This is another factor that becomes important.

      Reply
  9. Anthonia Obioha

    Doctor please can I presently conceive with this result because am not happy right now. I urgently need your response.

    Reply
  10. jerusha

    Am 37yrs.i was found to have an ovarian cyst and fluid in the pod after the first scan.when the second scan was done cysts were no more but the fluid in the pod was still found.i was given drugs by a gynecologist.and thus feel some improvement .three days after finishing drugs i experienced diarrhoea, a greenish discharge with an odour from the vagina yesterday morning and and it is no more.plis help me to know the essence of fluid whether it is a recovery sign or still there is a problem

    Reply
    1. Buddy M.D. Post author

      Since this was a one time symptom, it’s unlikely to be any infection. Could be a side effect of pills you were taking.

      However, if such a thing occurs again, you may need to see a doctor.

      Reply
  11. Lucy

    I am 34. I have been feeling dull persistent pain in my left lower abdomen.I have also had the heaviest menses with big clots for the 2 months in question. When i touch the left lower abdomen i can feel something which is painful to touch. Did a scan and the result said there is mild free fluid in the POD.Doc said i have an STI and prescribed a stat dose of ciprofloxacin (500mg), stat dose of scenidazole and Doxycycline for 7 days. I have just finished the Doxycycline but there has not been a change yet. Was the diagnosis and treatment given accurate?

    Reply
  12. ajayi opeyemi

    I took mistoprostol in November 20 which I was bleeding since then I went to meet a doctor for scan and the doctor said nothing is wrong with my uterus but she said DAT my pouch of Douglas is filled with fluid and which I took antibiotics but since then I have been having spot brown blood

    Reply
  13. Oma

    Hello doc good evening last week I saw my period with lasted for 5days with heavy flow (dark blood) and below my stomach am feeling pains there not only that my stomach has increased in size and my breast has increased a bit and am feeling pains on my breast so I decided to do a pregnancy test (blood test) and the result was negative so I decided to do a scan and nothing was only a mild fluid in the pouch of the Douglas I was advised to repeat a pregnancy test in two weeks time pls doc what it mean am tired of feeling this pains I can’t sleep well my stomach keeps on increasing

    Reply
    1. Buddy M.D. Post author

      Looks like a pelvic infection. You may need antibiotics.

      Go for relevant investigations at your facility.

      Reply
  14. Helen

    Hello, 8 months ago I was prescribed antibiotics for vaginitis due to gardnerella vaginalis. I had then some issues with my bowel and a pain on the right side of the abdominal, pain during urination and pain after intercourse. I run several blood tests, crp levels etc and it was all ok,as well as the cervix amd vagina swabs. Then the pain was worse and they found free fluid in douglas. I took 7 days antibiotics and the fluid cleared up after a month,but the pain on the right side of the lower abdonimal and inside the right part of my vagina never really went away.
    I visited a gastrenterologist and run some tests took mote antibiotics but the pain persists. I had several ultrasounds as well as magnetic scans and the pelvic organs seem ok.
    My question is: is it possible that the pid was never really cured since the never detected the bacteria that caused it ( or maybe gardnerella vaginalis had travelled up) and the antibitoics were not successful or it might have left some sensitivity in the whole area? Pain iw worse when sitting, worse after ovulation and there is pain after intercourse. It is more like a burning sensation that starts from the right ovary and reaches down the lower part of the vagina…..it all started after that vagintiis was detected…before that there was no problem…so I find it difficult to believe it could be endometriosis ( ultrasound and mri showed no sign of it). Whitw blood cells and crp levels all ok no bacteria decteded but tenderness of abdomimal alone plus feeling run down could mean PID? Please,help

    Reply
    1. Buddy M.D. Post author

      It’s difficult to comment what this could be without actually seeing your reports.

      From what you’ve shared, looks like your pelvic infection was not completely cured.

      Reply
  15. MERCY

    Hi Doctor,

    i feel a biting sort of pains mostly in my left side of abdomen and sometime itches , i also experience serious back ache, joints ache, a week before and during my cycle. so i went for ultrasound,blood and vagina test. And the result revealed:
    * Bulky and non-gravid uterus measuring 10.5 x 8.8 x 6.7cm in size and about 320.9cm by volume.
    * Visible and anteriorly displaced endometrial plate by posterior hypoechoic mass, measuring 10.0mm
    thick. No gestational sac nor retained product of conception was seen.
    * The myometrium harbors posterior hypoechoic intramural mass measuring 6.1 x 4.7cm in size, the
    rest of the myometrium are poorly homogenous.
    * The LT adnexal harbors a cystic mass with immeasurable wall, thin septations and anechoic content,
    this cyst measured about 7.6 x 5.0cm in size. the RT is free.
    * Mild fluid collection in pouch of douglas was noted.
    * The urinary bladder appears normal.
    * upper abdominal scan reveals normal spleen, liver, pancreas and gallbladder. (no abnormality seen
    in these organs).
    * IMPRESSION: Bulky Uterus in anteversion.
    – No cyesis.
    – Uterus Fibroid.
    – LT adnexal cyst.
    – Mild Fluid collection in pouch of douglas – ? pelvic infection.
    WHAT COULD BE THE INTERPRETATION AND POSSIBLE TREATMENTS.
    PLEASE!!! i need help as this seems frightening. CAN I EVER CONCEIVE?

    Reply
    1. Buddy M.D. Post author

      Your condition is treatable. Once treated, you’ll be able to conceive naturally.

      Pelvic infection needs to be attended first. Appropriate antibiotics would be given.

      After that, treatment for fibroid would be assessed. Mostly, surgical resection/ scraping off is done for this.

      Reply
  16. Ebele

    I’m 34yrs old, I’ve being spotting since over a year after delivery through cerclage, and this has made me loose weight. I went for a pelvic scan and this is the result. An anteverted uterus with homogenous myometrial echo texture’, nil leiomyoma. The endometrial plate is thick and regular’, measuring 5.7mm’.nil gestational sac’. nil retained product of conception. Both adnexa are free’. nil complex ovarian lesion seen. Substantial fluid collection is noted within the Pouch of Douglas. IMPRESSION:Normal uterine outline. Thick & regular endometrium ‘, nil gestational sac’, nil retained product of conception. PID HVS is advised. Please doc explain the result for me and advise me on what to do. Thanks.

    Reply
    1. Buddy M.D. Post author

      This is not normal and there has to be a cause for your spotting.

      Your reports show that your uterine lining is quite thick. This may be bleeding out. Likely to be some hormonal issue.

      Your doctor may suggest treatment with hormonal pills.

      He may also screen you for the presence of any infection.

      Do you have any pain in back, lower abdomen, fever etc?

      Reply
      1. Ebele

        Thanks for your response. I don’t have back pain, fever or pain in lower abdomen. I have loose weight from 58 to 46 now. And I also loose strength at times.

        Reply
        1. Buddy M.D. Post author

          Doesn’t appear to be an infection. Looks more like a hormonal issue.

          Losing strength is likely to be related to the blood loss you are suffering. Your doctor may put you on iron supplements to restore back your strength.

          Reply
  17. Mary

    Hello
    I have been having constant pain ffor over 6 months in my left and right sides just under my ribs. I had a uti which was treated with Cipro. Still the pain did not go away. My sex drive has lowered dramatically. I went for Ctscan showed slightly enlarged spllen and liver along with swollen peri lymph nodes. I was told again I had another uti treated with Cipro. I went today for a pelvic ultrasound. Dr. Saw an ovarian cyst meaauring 3cm on left ovary and a concerning amount of free fluid in cul de sac. Pain gets worst everyday on the sides and lower back. Urine is light colored no foul smell does not itch or burn. Period are regular every month. Feel weak amd dizzy also very pale to the face

    Reply
  18. Rosemary

    I’v been having lower abdominal pain, foul vagina discharge, mild itch(but not often). So I did several test including blood, urine, vaginal swab and pelvic scan. No abnormalities in blood and urine. Vaginal swap showed Epith cells : H, Pus cells: +, (Rbcs, Bacterial, T. Vaginalis and Yeast-like Cells): Nil.
    While the pelvic scan showed the uterus measured 62.3mm x 47.3mm x 46.7mm in longitude, transverse and AP dimensions respectively. The endometrial plate measured 9mm in thickness. Complex fluid in the pouch of douglas with depth 37.2mm. The liver, gallbladder, spleen, pancreas and kidneys are grossly normal. No free intraperitoneal fluid. Impression; Pelvic inflammatory disease.
    I was prescribed some antibiotics, which I took as instructed. But the symptoms still persist. Does this really imply PID. What do I do?

    Reply
        1. Buddy M.D. Post author

          This dose sound like PID. If you still have the foul smell, get in touch with your doctor again. She may have to change your antibiotics.

          Reply
  19. linda

    Hi Doc

    I have a bacterial infection in my belly button.
    I have been prescribed trimovate to use in the infected area.
    I just wanted to know if this medicine is supposed to be applied inside the belly button and how deep?
    as I get discharge.

    Reply
    1. Buddy M.D. Post author

      You may apply it nicely over the area, covering the belly button, inside it and surrounding affected region.

      However, this medicine may just alleviate your symptoms and not cure the cause. This is a steroid cream. You need to apply some antibiotics for cure.

      Reply
      1. linda

        Hi again

        the trimovate cream did reduce the discharge abit and some of the discomfort, i have used it for 6 days and have told to complete the 7 day course. However, as you mentioned it has only slightly improved my symptoms. i still do get discharge with blood (its a bit sticky too) and i also get discomfort in the belly button when the discharge is there and i havent cleaned it out with a tissue (is this normal?).
        After speaking to the doctor i have been prescribed flucloxacillin 500mg 4 x a day for a week.
        Will this cure the infection?
        amoxicillin doesnt usually cause me any symptoms but i have heard this medication has many side effects so im a bit worried.

        Please doctor i hope you can address these questions.
        Thanks alot in advance

        Reply
        1. Buddy M.D. Post author

          As we mentioned earlier, Trimovate is just to relieve your symptoms, it’s not a cure. You definitely need to take antibiotics at the earliest.

          You may start with the prescribed dose of flucloxacillin. This is essential to cure your infection. Since the medicine is being given for a very short duration, you don’t have to worry about the side effects.

          Reply
  20. Susan Nyambura

    I have irregular periods since I started my menses in 2009,,I miss my period for some months and when it appears its heavy and can last for a month..I did ultrasound and the result shows that my endometrium stripe measures 2.78cm.Also a free fluid noted in the endometrial cavity and at the ant de sac..I have been trying to conceive for 2 years.What might be the problem?

    Reply
    1. Buddy M.D. Post author

      Your endometrium appears to be quite thick. Also, it’s not normal to be hawing fluid in those sacs, as you’ve mentioned.

      This may be some hormonal disturbance that’s giving you a problems and also interfering with conception. You need to get in touch with your gyne for evaluation. She may order a hormonal assay for you, assessing their levels and cause of all problems.

      Reply
  21. Linda

    I was feeling pain in my abdomen I want to take a scan and the scan read, uterus with homogeneous appearance,normal endometrial stripe,both ovaries are normal in shape,normal adnexal,normal outline of cervix with normal echo pattern but moderate fluid collection seen at the posterior cul-de-sac will be able to conceive?

    Reply
  22. Lizzie

    Hi

    I recently had an ultrasound that showed I have a simple cyst on my left ovary and with it 2 daughter cysts. I’m 26 and have had this cyst for years though the daughter cysts is something new. I get pain in my left side which can be managed with the progestogen pill. I get pain during sex and my cycles have been all over the place, I’ve bled 3 times, all of different flows within the space of a month and I also have fluid in my pouch of Douglas.

    I took an sti test and that came back negative, I get UTIs quite often and I just dont know what to do anymore. I’ve had this issue now since I left uni at 21 and no one seems to be able to get to the bottom of diagnosing or treating me. I want kids eventually and am worried this will stop that if they don’t figure it out.

    Reply
    1. Buddy M.D. Post author

      Can you share your ultrasound report? How big are the cysts? Are they reducing in size? What medicines are you taking?

      Also, did you get your thyroid hormones checked up?

      Reply
  23. Temmy

    Hy doctor
    I’m 28, I do have heavy menstrual flow every month and a virginal discharge a week immediately after my period. I went to hospital and I was asked to do scan and the result reads”Urinary bladder shows normal wall thickness and contains clear urine.
    Bulky uterus measuring 7.0cm in AP diameter. It demonstrates multiple rounded slightly hypoechoiec intramural masses of various with the largest measured 5.4×4.5cm in the body anteriorly. There’s POD FLUID collection and the adnexae are free.
    I was prescribed trexanamic acid to control the flow and antibiotics for the discharge but the signs still persist. Please help me, what can I do? I’m not comfortable with it at all.

    Reply
    1. Buddy M.D. Post author

      You need to see a gynecologist dear. It won’t be enough to control the bleeding. We also require to treat those intra mural growths. This is usually done by starting hormonal pills in regulated doses.

      Only the very big and bulky ones may require surgical removal.

      Reply
  24. Amy

    I’m in and out of hospital every couple of weeks with severe lower abdominal pain, fever, rapid heart beat, diarrhea, vomiting and dizzyness. I have bled constantly for 17 months and yesterday they found free fluid in the pod and was suspicious of endometriosis but sent me home so now I’m not sure

    Reply
    1. Buddy M.D. Post author

      Looks like you,re getting lower GI infections repeatedly. You need to care care of what you eat and drink. Let all food stuff be fresh, thoroughly clean and properly cooked to make it easily digestible.

      Prolonged bleeding depletes iron stores of the body. You,re likely to be anemic. This may be confirmed from a simple blood work.

      Iron correction needs to be done immediately. This would check that rapid heart rate and weakness you must be having.

      As for the gyne part, investigations performed under a gynecologist would reveal diagnosis. If it’s endometriosis, earliest treatment is recommended.

      Reply
    1. Buddy M.D. Post author

      Food stuff that can be categorized under JUNK FOOD, like, white breads, pastas, noodles, refined sugars etc. may alter hormonal levels, and enhance fibroid growth.

      If you eat healthy, that will definitely benefit in a long run. Consume whole grains, plenty of fresh fruits and vegetables.

      Reply

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