Pouch of Douglas cavity abscess in males and females: symptoms, causes, treatment

Medically reviewed: 15, February 2024

Abscesses of the pouch of Douglas

Abscesses of the pouch of Douglas are circumscribed collections of pus that arise in the lowest part of the abdominal cavity: excavatio rectovesicalis in men and excavatio rectouterina in women.

One of the most important features of the peritoneum is its ability to delimit foci of infection from the infection-free abdominal cavity. This delimitation occurs first due to fibrinous adhesions, and later due to increasingly dense adhesions. It is thanks to this protective mechanism that the body in many cases is protected from generalized peritonitis.

The infection can enter the peritoneum as a result of inflammatory diseases of the appendix, female internal genital organs, stomach, liver, bile ducts, etc., as well as during operations in which the lumen of any hollow organ was opened. Since the spread of local and parenteral antibiotics, the picture of generalized peritonitis has become less severe; now it does not pose such a formidable danger to the patient as before the era of antibiotics.

However, infectious agents located in isolated intra-abdominal abscesses usually do not respond to antibiotics because these drugs are unable to penetrate the thick membrane surrounding the abscess.

The pouch of Douglas abscess is an encapsulated purulent focus. It is located in the uterorectal recess in women and the rectovesical recess in men.

The disease is characterized by nonspecific manifestations and local symptoms. To confirm the diagnosis, various methods of laboratory and instrumental diagnostics are used (pelvic ultrasound, CT, abscess puncture, etc.). Treatment of a pouch of Douglas abscess involves opening it, draining and sanitation, as well as administering antibiotic therapy.

Abscesses of the pouch of Douglas occur most often after surgery for destructive appendicitis.

Thanks to the topographical features of this area and the plastic properties of the peritoneum, favorable conditions are created for delimiting the pus that has accumulated here from the free abdominal cavity. The sheets of peritoneum, loops of small and large intestines and the omentum, fused together, form a capsule surrounding the purulent cavity.

In anatomy, the term “Douglas space” refers to excavatio retnouterina in women, while in surgery this term is often not entirely accurately used to refer to excavatio rectovesicalis in men.

In the presence of acute appendicitis, pus from the appendix can enter the pouch of Douglas in various ways:

According to our and literature data, the time of appearance of such an abscess ranges between 5-25 days after an attack of acute appendicitis. The sizes of abscesses vary: from small, containing 50-100 ml of pus, to huge, reaching the level of the navel and containing 500-600 ml of pus. Some authors of medical scientific works also distinguish iliopelvic abscesses, which in their further development can become separated, taking the shape of an hourglass.

In an adult male, the distance from the anus to the bottom of the rectovesical fossa is approximately 5–6 cm, and in women, the distance between the vaginal opening and the bottom of the pouch of Douglas varies between 4.5–10.8 cm (Waldeser). Therefore, the bottom of the abscess is accessible for examination and surgical intervention through the rectum.

Pouch of Douglas Abscess Causes

The destructive form of acute appendicitis with the pelvic location of the appendix is considered the main cause of the formation of an abscess in the pouch of Douglas. In women, the risk of developing this pathology increases in the presence of purulent diseases of the appendages (adnexitis, pyosalpinx).

There is an opinion that the occurrence of an abscess in the pouch of Douglas after appendectomy can be facilitated by abdominal tamponade. This opinion is based on the fact that when the abdominal wall is tightly sutured, pelvic abscesses are much less common than when tampons are inserted into the abdominal cavity. Most likely, the percentage of these ulcers increases after tamponade can be explained by the fact that the abdominal cavity is tamponed in patients with the most severe destructive appendicitis.

Other causes of pouch of Douglas abscess include:

• perforation of the colon diverticulum;
• paraproctitis;
• diffuse forms of peritonitis.

The most common pathogens of purulent infection are staphylococci, Escherichia coli and paracoliforms, streptococci, etc.

Pathogenesis of Pouch of Douglas Abscess

The abscess of the pouch of Douglas is formed secondarily (against the background of other purulent diseases). The anatomical features of the pelvis contribute to the flow of blood, pus or serous effusion into the pouch of Douglas. Conditions for the formation of an abscess are created due to insufficiently thorough inspection of the surgical wound and its inadequate drainage.

Pouch of Douglas Abscess Symptoms

Most often, an abscess in the pouch of Douglas begins to form 5-10 days after surgery for a primary purulent disease. Among the main symptoms of the pathology are:

• sudden chills;
• increased body temperature;
• cardiopalmus;
• feeling of nausea;
• headache;
• bursting and sharp pain in the lower abdomen, the intensity of which increases with movements and physiological functions.

Patients may complain of frequent and painful urination, unstable stools, increased gas production and fecal incontinence. The intensity of clinical signs depends on the size of the abscess and the stage of the disease. To prevent the development of severe complications, it is recommended to consult a doctor when the first symptoms appear.

Complications

Large abscesses in the pouch of Douglas can lead to compression of the rectum. This causes mechanical intestinal obstruction. Lack of timely treatment and progression of the disease increase the risk of spontaneous breakthrough of the abscess into the abdominal cavity or hollow organs (bladder, uterus, rectum). Pelvic vein thrombophlebitis and thromboembolic disease are also considered complications of long-standing pouch of Douglas abscess.

Pouch of Douglas Abscess Diagnostics

At the initial consultation with a gastroenterologist, complaints and medical history are collected. You should pay attention to recent surgeries and illnesses. This will help the doctor determine the likelihood of an abscess forming in the pouch of Douglas.

Next, the specialist begins the examination. During palpation, pain in the pelvic area, local muscle tension, and a positive Shchetkin-Blumberg sign are determined. Rectal or vaginal examination can reveal a painful infiltrate. The pouch of Douglas abscess in women is located above the cervix. In this case, the overhang of the posterior vaginal vault is determined.

Differential diagnosis is carried out with the following conditions:

• tubo-ovarian abscess;
• prostate abscess.

Recognizing a pouch of Douglas abscess is generally not very difficult, but it is important to identify this complication in a timely manner. In case of any unsmooth postoperative course, especially after removal of perforated or gangrenous processes, it is necessary to systematically, and perhaps daily, perform a digital examination per rectum or per vagina.

Urination problem

Patients’ complaints of defecation and urination problems are of great importance for the diagnosis. Frequent loose stools mixed with mucus and sometimes tenesmus are symptoms indicating the formation of an abscess on the pelvic floor. Along with these symptoms, and sometimes a little later, complaints of frequent urination, difficulty in urinating, and sometimes pain at the end of urination appear; urinary retention is occasionally observed. Frequent and painful urination is considered one of the early symptoms of a pouch of Douglas abscess.

Dyspeptic symptoms are usually absent. Sometimes there are mild pains in the abdomen above the pubis, which do not bother the patient much. Usually the abdomen is not swollen, soft, painless, except for a narrow area above the pubis, where pain is detected on palpation. If the abscess is well demarcated, there are no symptoms of peritoneal irritation. In more advanced cases, there is bloating, which can be caused by intestinal paresis.

Body temperature check

The body temperature is always elevated when an abscess develops in the pelvis, and two types of fever are possible. In one of them, after an appendectomy, the temperature drops to normal levels, and then rises again a week or later. In another option, the temperature after the operation does not decrease at all and further reaches a high level (38.5-39°). It should be noted the diagnostic value of temperature measurements in the armpit and rectum. Instead of the usual temperature difference of 0.2-0.5° with an abscess of the pouch of Douglas, it reaches 1.1-1.4°.

The general condition of patients remains satisfactory or sometimes reaches moderate severity. The pulse corresponds to the temperature.

Changes in the blood with an abscess of the pouch of Douglas, as usual, are manifested by leukocytosis, a shift in the white blood count (usually to a moderate degree) and an accelerated erythrocyte sedimentation reaction.

Rectum examination

When digitally examining the rectum, relaxation of the anal sphincter is noted. Due to the defeat of n. pelvici, the tone of the sphincter decreases, which leads to its weakness and poor retention of feces and gases. Sometimes there is even a gaping of the anus. By examining the rectum day after day, a definite evolution of symptoms can be established. Initially, only pain in the anterior wall of the rectum is determined, then it is possible to establish its overhang; when examined per vaginam – pain in the posterior fornix. After another 2-3 days, the site of bulging of the rectal wall thickens and turns into a painful infiltrate; the intestinal mucosa stops shifting. Some more time passes, and softening is detected in one of the areas of the infiltrate; the examining finger sometimes seems to fall through the dense formation. This symptom is a signal for the transition from conservative to surgical treatment.

Puncture of an abscess through the rectum or vagina as a diagnostic technique is not recommended due to the danger of puncturing adjacent intestinal loops. It is permissible only if there are clear signs of suppuration immediately before the intervention, on the operating table to clarify the location of the opening of the abscess.

As with any acute inflammatory process, the formation of an abscess in the pelvis is often preceded by an infiltration stage. At this stage, the possibility of achieving resorption of the infiltrate with appropriate treatment is not excluded.

Here is one such example.

Patient, 23 years old, 4 days after the onset of the disease.
Acute appendicitis was diagnosed. During the operation, serous exudate was
discovered in the abdominal cavity. The modified vermiform appendix was
isolated from the adhesions. Appendectomy.

The first 5 days of the postoperative period proceeded well. Then pain appeared in the lower abdomen. The temperature rose to 38.7°. Urination is difficult. An inflammatory infiltrate was clearly palpable through the rectum and vagina.

Diagnosis of subdiaphragmatic abscess is difficult, especially when it is small in size and in its initial forms. The subphrenic abscess develops gradually after removal of the appendix. It does not always extend to the entire right half of the subdiaphragmatic space, occupying only part of it, either closer to the anterior or posterior or to the center of the dome of the liver.

Unusual pain localization

Usually, after a certain clear interval, at various times from the moment of surgery, symptoms of a purulent focus of unclear localization reappear. The pain is felt either in the lower chest on the right or in the upper quadrant of the abdomen. Sometimes a painful, dry cough occurs, caused by irritation of the phrenic nerve. The last symptom was first pointed out by A. A. Troyanov. Then the pain is concentrated in the right hypochondrium, especially with deep breaths, and often radiates to the right shoulder blade and shoulder.

Sometimes the affected side of the chest lags behind in breathing movements. In more pronounced cases, there is protrusion of the epigastric region and smoothness of the intercostal spaces. These are significant symptoms and you need to be able to notice them early. In advanced cases, even upon examination, a protrusion of the right “side” is detected; some surgeons consider pain when swallowing to be one of the early signs of a subdiaphragmatic abscess. In some cases, swelling of the lower chest occurs.

The abdomen remains soft, and slight tension in the right hypochondrium is rarely detected. The liver is pushed down by exudate, so it often protrudes from under the costal margin, but is usually not painful. There is no jaundice. In rare cases, nausea occurs, and even less often, vomiting or hiccups. N.I. Gurevich attaches great diagnostic importance to the Kryukov symptom – pain when pressing on the area of the lower intercostal spaces, which he considers an early and almost constant sign.

Chest examination

When examining the chest, dullness is determined in its posterior lower part on the right with weakening of breathing and vocal tremor there. An increase in the upper limit of hepatic dullness in the form of an upwardly convex arch is characteristic. In some cases, subdiaphragmatic ulcers contain gas – a waste product of putrefactive microbes. Then, upon percussion, three zones are obtained: the normal pulmonary sound passes at the level of the abscess into a more or less high-pitched tympanitis, and then hepatic dullness appears again.

Subphrenic abscess is a serious disease; the temperature is high, remitting, often with chills and profuse sweating. There are blood changes corresponding to an acute purulent process.

To recognize a subphrenic abscess, the x-ray examination method is of great help. When X-raying the chest, a high position of the diaphragm, limitation of its movements or its complete immobility are revealed quite early. The presence of a gas bubble with a horizontal level of fluid under the diaphragm is an almost pathognomonic sign of a subdiaphragmatic abscess.

A test puncture is crucial. It should be performed under local anesthesia with the patient in a sitting position with the right arm abducted and raised high. When choosing a place for puncture, one should be guided by chest percussion data, the most pronounced pain when pressing on the intercostal spaces and x-ray data. For the most part, this is located in the anterior or middle axillary line, at the level of the ninth and tenth intercostal spaces.

Often the puncture has to be repeated many times before pus can be obtained. When the needle is positioned correctly in the subdiaphragmatic space, it lowers when inhaling and rises when exhaling. It is recommended to direct the needle lower, the higher the puncture site. If the needle passes through the pleural cavity, then a two-layer exudate is often obtained: a transparent exudate (sympathetic pleurisy) is sucked from the pleural cavity close to the surface, and pus is sucked from the depths of the subphrenic abscess.

Pouch of Douglas Abscess Treatment

Treatment with antibiotics (penicillin, streptomycin), hot enemas, novocaine lumbar blockade.

To confirm the diagnosis, various laboratory and instrumental methods are used: pelvic ultrasound, prostate ultrasound, CT and/or MRI. A diagnostic puncture of the abscess allows definitive recognition of an abscess in the pouch of Douglas. The manipulation is carried out under ultrasound guidance through the rectum or posterior vaginal fornix. The biomaterial obtained during the procedure is sent for bacteriological examination.

The scope of diagnosis is determined individually by the attending physician. This takes into account the patient’s complaints, his age, general condition and concomitant diseases.

Conservative treatment of infiltration of the pouch of Douglas is reduced to the prescription of bed rest, antibiotics and small (50-75 ml) warm enemas with a water temperature of 38-40 ° (2 times a day) or alcohol and calcium enemas, as well as hot douching in women.

In cases where there is already an accumulation of liquid pus, there is little hope for the success of conservative treatment. Once an accumulation of pus in the fossa of Douglas is recognized, there should be no delay in surgery.

Immediately before the operation, it is necessary to take care of emptying the bladder with a catheter and a cleansing enema. Currently, it is customary to open the abscess of the pouch of Douglas per rectum in men and children and through the posterior vaginal fornix in women.

Surgery for pouch of Douglas abscess

The technique of the operation is as follows.

Under local, or less commonly, general anesthesia, the anal sphincter is stretched, first with the fingers and then with a rectal speculum. After this, it is easy to insert a vaginal speculum into the anus. The rectal mucosa is wiped with a ball dipped in alcohol. Some surgeons recommend lubricating it with a 10% novocaine solution. Once again, use your finger to guide the location of the softening area. In some cases, the eye can see a bulging wall of the ampoule, covered with dull, reddened, easily bleeding mucosa. A puncture is made strictly along the midline, in the area of softening identified by palpation, and pus is sucked into the syringe.

Without removing the needle, carefully cut through the intestinal wall. It is not recommended to immediately make a wide incision in the intestinal wall to avoid bleeding from the hemorrhoidal vessels. After opening the abscess, the wound is slowly and bluntly widened using a finger and gradually opened jaws of a forceps. A drainage tube is inserted into the purulent cavity, which is fixed with one suture to the skin of the perineum. Some surgeons (E. Graser, Welborn, etc.) consider the introduction of drains not necessary.

In women, vaginal opening of the abscess is indicated. The surgical technique is similar to that just described. After inserting the speculum and moving the uterus anteriorly, access to the posterior fornix opens. Puncture, tissue dissection along the needle, blunt expansion of the wound opening and insertion of a drainage tube are performed.

When opening pelvic abscesses, some complications may occur (damage to one of the intestinal loops, injury to the bladder).

Sometimes there is bleeding from the wall of the rectum. To reduce the chance of bleeding, the incision should be made strictly along the midline, where there are fewer blood vessels. You can also use a hemostatic sponge. There are usually no deaths from these bleedings.

The postoperative period after opening the abscess of the fossa of Douglas, as a rule, goes smoothly. After a few days, the temperature drops to normal levels, the discharge of pus stops, and patients quickly recover.

After the operation, the doctor prescribes a light diet, opium to retain stool while the drainage is in the rectum, and intramuscular antibiotics.

Premature rapprochement of the wound edges leads to retention of pus and the resumption of previous symptoms of the disease. In such cases, it is enough to bluntly widen the hole in the intestinal wall again to ensure emptying and drainage of the purulent cavity and achieve complete elimination of the process.

Abscesses of the pouch of Douglas left without surgical treatment often lead to severe complications. An infrequent, but most dangerous of these complications is the breakthrough of an abscess into the free abdominal cavity with the inevitable development of diffuse peritonitis. Often an abscess breaks through into adjacent hollow organs and most often into the rectum. Clinically, such a breakthrough is characterized by the admixture of a significant amount of pus in the stool, which mostly leads to self-healing. More dangerous is the breakthrough of pus into the bladder, which causes frequent urination and a significant admixture of pus in the urine. A rupture of an abscess into the bladder can lead to a severe ascending urinary tract infection.

The literature describes isolated cases of pus breaking out from the pouch of Douglas into the vagina, into the cecum, and in children – into the navel. Morison’s observation is unique. In his patient, the right fallopian tube served as a drainage, through which pus was evacuated from the fossa of Douglas into the uterine cavity, and the patient recovered.

To prevent abscesses of the pouch of Douglas, it is necessary during the operation to remove the appendix, especially with gangrenous and perforated appendicitis, to reliably delimit the lesion from the free abdominal cavity with tampons, and in the presence of pus, thoroughly drain the peritoneal cavity and especially the small pelvis from the accumulated exudate.

It is easy and quick to dryly remove exudate or blood from the abdominal cavity (especially from the pelvis) using a pump. Drying all the nooks and crannies of the peritoneal cavity with napkins is usually imperfect and may be one of the reasons for the occurrence of encysted abscesses.