What Is Pouch Of Douglas In Pregnancy?

What Are the Uses of the Pouch of Douglas? – The pouch of Douglas is a good site for peritoneal dialysis, making it invaluable in patients with end-stage renal failure. A catheter called the Tenckhoff catheter is placed in the pouch (specifically the distal end) and may even be sutured to the bladder.

1. This helps prevent the migration of the bladder.
2. Conclusion: By itself, the pouch of Douglas is simply an anatomical structure that displays some fluid collection throughout the course of a woman’s menstrual cycle (or during her childbearing years).
3. However, it should be noted that the pouch of Douglas is a central area or location for seeded lesions due to its dependency when upright or supine.

Most cases of pouch of Douglas pathologies are treatable, and malignancies occur very rarely, making this an area of interest but not a cause for excessive concern. Last reviewed at: 01 Aug 2022 – 5 min read
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Is pouch of Douglas normal?

Early in 2014, journalist and media teacher Tracy Sorensen was diagnosed with Stage IIIc primary peritoneal carcinoma. She was treated with chemotherapy and radical debulking surgery, and is now in remission and writing about the experience. This is an extract from a longer work in progress.

• A version of this work was first published on her website, The Squawkin’ Galah ( http://squawkingalah.com.au ), on 23 October 2014.
• The pouch of Douglas is a small area in the female human body between the uterus and the rectum.
• It has a name and a shape, but the essence of it, the point of it, is that it is a piece of nothing.

The territory of the pouch of Douglas is infinitesimal; because when all is well, the surrounding organs slide against each other like two slugs in a mating dance. The pouch of Douglas, like the pouch of a mother kangaroo or a coin purse, can expand to accommodate growing or multiplying things.

• The pouch takes its name from Dr James Douglas, an 18th century Scottish man-midwife who wrote anatomical treatises and held public dissections in his own house.
• In 1726, a woman by the name of Mary Toft, who lived in Surrey, England, announced that she had given birth to baby rabbits.
• Her local doctor was astonished and ran off to let everyone know.

She had been in normal labour, he said, with regular contractions. And then appeared the baby rabbits. The woman enjoyed her celebrity. But Dr Douglas smelled a rat. He went to see her himself, to put an end to the nonsense. He examined her and declared her a fraud.

1. William Hogarth later made an etching of Dr Douglas standing at Mary Toft’s bedside, gesticulating, with the rabbit children running off in all directions, unmasked and embarrassed.1 Rabbits came to Australia with the First Fleet.
2. Like currency lads and lasses, they grew healthy on fresh air and good eating.

They eloped into the bush and ate the crops that were planted for them and built burrows in the new estates that opened up as far as the eye could see. Australia’s emblem bore the kangaroo and emu, but the continent was in fact governed by rabbits. The anti-rabbit wars, when they came, were conventional and chemical; mass slaughter and hand-to-hand combat.

1. By the time I could walk and talk, I knew that rabbits had to be caught and killed.
2. Even the family cat could do its bit.
3. Go and catch a rabby, Ginge”, my mother urged the big hard tomcat that went with the dairy farm my parents worked for a while.
4. That was in the south of Western Australia, where it was green and lush and muddy.

That’s where my sister and I had the job of herding calves. We always stopped to examine the hot pats of manure. We noted that some were sloppy, some firm. We wore plastic galoshes. Dad was always hosing out the stalls where the cows had been. Mum grew tomatoes at the back door of the weatherboard soldier’s settlement cottage that we rented from the farmer.

• My partner Steve walks over land near Bathurst, in New South Wales, that was box gum, then eaten-out farmland, and is now a land care reserve.
• He stops at likely spots and takes coordinates with his pocket GPS.
• These are rabbit burrows.
• Rabbits eat the delicate native grasses being coaxed back onto the land.

Someone else will come by, later, to gas the burrows. The rabbits will lie there, dead, under the ground. We go walking with our black Labrador, Bertie. Bertie is getting old and pretends not to see rabbits, because he can’t be bothered to give chase. Kangaroos stand stock-still as we approach.

The full, hanging pouch with just the joey’s legs sticking out. There’s something in my own pouch. Cells are multiplying, well fed and happy, burrowing down in new estates. They’re going wild, like rabbits. Dr Douglas named his pouch of nothing. Nothing is like a magnet for something. Nothing is a big blank page with a pencil beside it.

Nothing can be a blessed relief. There is nothing there. I slide on my conveyor belt into the big white donut machine. The warmth of radioactive fluid is strange at the back of the neck and around the bladder. “Breathe in and hold.” Pause. “You may now breathe normally.” At this point, I have never heard of Dr Douglas or Mary Toft or her baby rabbits.

They belong to the new country on the other side of the donut. My rabbits are multiplying. Rabbits need Lebensraum, Some must leave the pouch of Douglas for opportunities elsewhere. It’s dark and wet and they can’t see where they’re going. They’re like baby kangaroos, blind and pink-skinned, groping their way towards the teats inside the pouch.

Only this journey is in reverse. They must burrow upwards, as if towards the light, but there is no light, only another soft place to grow. They slip between organs, like a finger. They make room for themselves. Ginge moves stealthily through grass, his belly close to the ground.

1. He gives his hindquarters a tiny shake, springs through the air, brings down his prey.
2. He closes his jaw around the neck, drags his prize home.
3. Ginge stands at the back door, offering up his rabbit.
4. Good boy Ginge! Thank you very much.
5. But you have it, Ginge.” Ginge drags it behind the woodpile.
6. The flesh is soft and bloody.

Provenance: Commissioned; not externally peer reviewed.
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What is the treatment of pouch of Douglas?

What does culdocentesis mean? – Culdocentesis is the puncture and aspiration (withdrawal) of fluid from the pouch of Douglas or rectouterine pouch. Culdocentesis is the puncture and aspiration (withdrawal) of fluid from the pouch of Douglas or rectouterine pouch. The pouch of Douglas or rectouterine pouch is formed between the part of the gut and the uterus.

• The procedure involves the introduction of a needle through the vaginal wall into the pouch of Douglas.
• Blood, pus and other fluids in the abdominal cavity collect in the pouch because of its dependent location and gravity.
• It may be examined to diagnose diseases of the abdomen.
• Culdocentesis used to be a valuable procedure for the diagnosis of ectopic pregnancy,

However, due to the development and easy access to ultrasound (USG), culdocentesis is rarely performed. An ectopic pregnancy occurs when the fertilized egg or embryo implants and grows outside the uterus, most commonly in a fallopian tube (the tube that carries the eggs from the ovaries to the uterus).
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What is pouch of Douglas in ultrasound?

Primary Pouch of Douglas malignancies: A case series and review of the literature a Department of Obstetrics and Gynecology, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, 229899, Singapore Find articles by a Department of Obstetrics and Gynecology, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, 229899, Singapore Find articles by b Department of Gyneoncology, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, 229899, Singapore Find articles by Received 2017 Mar 15; Revised 2017 May 30; Accepted 2017 Jul 13.

• POD lesions are often diagnosed as ovarian or uterine in origin on imaging. • POD malignancies with concomitant endometriosis, appear to be of lower grade. • There is no consensus on the optimal treatment for rare primary POD neoplasms.

The Pouch of Douglas (POD), also known as rectouterine pouch and posterior cul-de-sac, is bordered anteriorly by the posterior uterus and posteriorly by the rectosigmoid colon. It is lined by peritoneum which originates from remnants of the Mullerian system which does not participate in organogenesis ().

• Due to the common embryology, benign and malignant lesions which mimic the Mullerian system can develop in the POD.
• A second mechanism for primary POD malignancies is the malignant transformation of endometriosis.
• Primary POD malignancies are rare.
• In an extensive search of current English literature, 31 cases of primary POD malignancies were identified, with the first case reported by,

Mullerian types POD tumors reported include adenosarcoma, carcinosarcoma, clear cell adenocarcinoma and papillary serous carcinoma. Other tumor types reported include placenta site trophoblastic tumor, malignant mesothelioma and extragastrointestinal stromal tumor.

This paper reports 11 cases of primary POD malignancies in a single center, the largest series so far in literature. Patients diagnosed with primary POD malignancies from January 2006 to December 2016 were identified from the cancer registry in KK Women’s and Children’s Hospital (KKWCH) Gynecology department.

The final diagnoses were based on intraoperative and histological findings after our multidisciplinary meeting. Intraoperatively, these tumors may be described to be located in the POD, rectovaginal pouch or rectovaginal septum. Data collected included age at diagnosis, presenting complaints, imaging studies, surgical findings, histology, treatment and progress.

There were 11 patients identified with primary POD malignancies in the past ten years (). All of them were diagnosed in KKWCH and had subsequent treatment within the same center except for one who returned to Malaysia after primary surgery. The youngest was 24 years old at diagnosis while the oldest was 74 years old.

The presenting symptoms were varied, including abdominal pain and distension, abnormal uterine bleeding, lump at introitus and reduced stool caliber. The majority were thought to have either uterine or ovarian pathology except for four whose pre-operative scans suggested POD malignancies.

Imaging modalities used included pelvic ultrasounds, magnetic resonance imaging (MRI) and computed tomography (CT). On histology post-operatively, there were seven adenocarcinomas (one unspecified, two endometrioid, one adenosquamous and three serous), two carcinosarcoma, one adenosarcoma and one perivascular epitheliod tumor (PEComa).

Three patients had synchronous endometrial and POD malignancies. Four out of the seven adenocarcinomas and the adenosarcoma were found to have concurrent endometriosis as seen on histology. Five patients have died of the disease. The remaining patients have had no relapses so far at this point of writing and were disease free between 6 months to 10 years.

Case no.	Age a	Presenting complaint	Imaging	Preoperative diagnosis b	Intraoperative finding	Histology of POD tumor	Concurrent endometriosis	Postoperative diagnosis	Treatment	Progress
1	51 years	Abdominal pain	US pelvis: 6 cm posterior cervical mass extending to lower uterine segmentMRI: 8 cm mass involving left posterolateral wall of uterus	Leiomyosarcoma	POD filled with tumor	Endometrioid adenocarcinoma grade 2	Yes	Stage II POD endometrioid cancer	Surgery (suboptimal debulking c ), adjuvant paclitaxel and carboplatin	Disease free 1 year 5 months
2	48 years	Prolonged menstrual bleeding	US pelvis: 0.7 cm posterior uterine wall fibroid	Endometrial complex hyperplasia, unable to exclude transformation to adenocarcinoma	2 cm rectovaginal septum tumor	Endometrioid adenocarcinoma grade 1	Yes	Synchronous Stage IA endometrial endometrioid adenocarcinoma and Stage II POD cancer	Surgery, adjuvant paclitaxel and carboplatin, radiotherapy	Disease free 5 years
3	39 years	Dysmenorrhea and menorrhagia	US pelvis: 2 cm posterior uterine wall fibroid	Endometrial endometrioid adenocarcinoma	8 cm rectovaginal septum tumor	Endometrioid adenosquamous carcinoma grade 2	No	Synchronous Stage IA endometrial endometrioid adenocarcinoma and Stage II POD adenosquamous tumor	Surgery	Unknown
4	43 years	Intermenstrual and postcoital bleeding	US pelvis:Cannot exclude underlying adenomyosis of posterior uterine wall	Endometrial endometrioid adenocarcinoma grade 2	POD obliterated, friable tissue at rectovaginal septum	Adenocarcinoma Grade 2	Yes	Synchronous endometrium endometrioid adenocarcinoma with POD tumor	Surgery, adjuvant paclitaxel and carboplatin, radiotherapy	Disease free 10 years
5	52 years	Reduced stool caliber	US pelvis: 8.1 cm complex mass posterior to cervixCTAP: 8.4 cm pelvic mass arising from upper vagina/cervix	POD mass	5 cm rectovaginal tumor	Papillary serous adenocarcinoma grade 3	No	Stage IIC POD papillary serous adenocarcinoma	Neoadjuvant paclitaxel and carboplatin, interval surgery, adjuvant paclitaxel and carboplatin, radiotherapy, vault brachytherapy	DWD 4 years 10 months
6	41 years	Abdominal discomfort and mass	US pelvis: 6 cm right pedunculated fibroid10 cm complex left ovarian cyst	FibroidLeft ovarian cyst	Caseating rumor in POD11 cm left ovarian tumor	Papillary serous carcinoma Grade 3Hemorrhagic ovarian cyst	No	Stage II POD papillary serous carcinoma	Surgery, adjuvant carboplatin and paclitaxel	Disease free 8 years 2 months
7	49 years	Irregular menstrual cycles, foul smelling vaginal discharge	MRI pelvis: 8.5 cm ill-defined mass in POD involving both ovaries	Metastatic ovarian carcinoma versus sarcomatous change of tissues in POD	1 cm rectovaginal septum tumor	Serous adenocarcinoma grade 2	Yes	Stage IIIC grade 2 POD tumor	Neoadjuvant carboplatin, interval debulking surgery, adjuvant carboplatin	DWD 3 years 7 months
8	64 years	Abdominal bloating, loss of appetite Previous THBSO for POD endometrioma at 63 years	US pelvis: 4.8 cm complex lesion in PODMRI pelvis: 5.4 cm complex mass in POD	POD tumor recurrence	Large pelvic tumor	Adenosarcoma with sarcomatous overgrowth	Yes	POD adenosarcoma	Surgery (suboptimal debulking), adjuvant doxorubicin	DWD 5 months
9	64 years	Abdominal bloatingPrevious breast cancer at 51 years old in remission	MRI pelvis: 7 cm POD mass	POD tumor	5 cm rectovaginal tumor	Carcinosarcoma	No	Stage III POD carcinosarcoma	Neoadjuvant carboplatin and paclitaxel, interval surgery	DWD 3 years 7 months
10	74 years	Lump at introitus	MRI pelvis: 7.5 cm mass in POD	Synchronous endometrial and ovarian cancer versus metastatic endometrial cancer	8.5 cm POD tumor	Carcinosarcoma	No	Stage IIIC carcinosarcoma	Surgery (suboptimal debulking), adjuvant paclitaxel and carboplatin	Disease free 6 months
11	24 years	Abdominal mass	CTAP: 22.2 cm abdominopelvic mass	Abdominopelvic mass	20 cm tumor arising from POD	Malignant PEComa	–	Stage IIIA POD PEComa	Surgery, adjuvant doxorubicin and ifosfamide	DWD 1 year

The POD is named after the Scottish anatomist, James Douglas. It is the most dependent portion of a woman’s pelvis and thus a common location for fluid, abscesses and drop metastases. Primary malignancy can also occur in the POD, albeit rare, with only 31 cases reported in English literature so far.

Evaluation of a POD begins with a thorough physical examination and is aided by a variety of imaging modalities. Pelvic ultrasound is usually the imaging modality of choice to evaluate pelvic masses as it is relatively inexpensive and does not require use of a contrast agent. MRI can be valuable if the lesions need further characterization or if better delineation of soft tissues is needed to plan for surgery.

However, due to rarity of primary POD malignancies and the varied presenting symptoms, POD lesions can be mistaken as lesions from ovarian or uterine origin or metastases. Case 10 () presented with a lump in the introitus and a routine pre-vaginal hysterectomy endometrial biopsy incidentally showed endometrial cancer.

The differential diagnosis based on the endometrial biopsy and the MRI finding of a POD mass was either synchronous endometrial and ovarian cancer or metastatic endometrial cancer. Cases 2 to 4 presented with abnormal uterine bleeding and pre-operative diagnoses based on endometrial biopsies were endometrial hyperplasia or endometrial cancer.

Their pelvic ultrasounds did not show any lesions in the POD suspicious for malignancy. POD tumors, which have invaded into the uterine serosa, may also appear as leiomyosarcoma or fibroids on scans, as seen in cases 1 and 6. The majority of the cases in this case series were Mullerian type malignancies with five out of the ten cases having concomitant endometriosis.

In a meta-analysis of studies comparing endometriotic associated ovarian cancers (EAOC) to non-endometriosis associated ovarian cancers (NEAOC) (), EAOC was associated with early stage and low grade disease. However, there were no significant differences in progression-free survival and overall survival between EAOC and NEAOC after adjusting for histology, FIGO stage and other confounding factors ().

Among the five patients with concomitant endometriosis, four of them had low to moderate grade POD adenocarcinomas and were disease free between 17 months to five years. For the patients with Mullerian type POD malignancies without concurrent endometriosis, one had moderate grade adenosquamous carcinoma, two had high grade carcinomas and two had carcinosarcomas.

• Two were dead with disease at 42 months and 58 months and the remaining two were disease free at 6 months and 8 years.
• Mullerian adenosarcomas are mixed neoplasms composing of benign epithelial and malignant stromal (sarcomatous) components, typically arising from the uterus.
• While adenosarcomas are generally of low malignant potential and have good prognosis, a subgroup which exhibits sarcomatous overgrowth have higher rates of recurrence and much poorer prognosis ().

The site of origin of adenosarcomas also affects their clinical behavior. Extragenital adenosarcomas are found to have higher rates of recurrence and mortality rates than uterine adenosarcomas (). There are five cases of POD adenosarcomas reported in literature (, ).

Due to the scarcity of cases, there is no consensus on optimal treatment for extragenital adenosarcomas. All five cases had primary surgery and three of them had adjuvant chemotherapy. Chemotherapy regimens included platinum based agents, ifosfamide and doxorubicin. reported complete response of recurrent POD adenosarcoma with sarcomatous overgrowth with doxorubicin.

In this present study, case 8 who had adenosarcoma with sarcomatous overgrowth was dead with disease at five months. She had suboptimal debulking surgery and adjuvant doxorubicin. In the case reported by Huang et al., the patient had optimal debulking surgery and also had complete resection of the recurrence.

1. Surgery is the mainstay of treatment for extragenital adenosarcomas and optimal debulking should be achieved whenever possible.
2. Extrauterine carcinosarcomas are very rare, with ten cases of primary POD carcinosarcomas reported in literature (,,,, ).
3. Carcinosarcomas are very aggressive tumors with poor prognosis.

Due to its rarity, the treatment is often based on prior experience with uterine sarcomas. All the ten patients with POD carcinosarcomas reported in literature had primary surgeries, four with adjuvant chemotherapy, one with adjuvant radiotherapy and one with both adjuvant chemotherapy and radiotherapy.

1. Chemotherapy regimens used included cisplatin with either ifosfamide or adriamycin or ifosfamide as single agent.
2. Six patients were dead with disease within 12 months.
3. The longest disease free interval was 60 months in a case reported by, in which the patient underwent optimal cytoreductive surgery, chemotherapy with ifosfamide and cisplatin and radiotherapy.

In this current study, two patients had carcinosarcoma of the POD. One had neoadjuvant paclitaxel and cisplatin with optimal interval cytoreductive surgery. Unfortunately her disease was progressive and she died after 43 months. The other patient had suboptimal cytoreductive surgery and adjuvant chemotherapy with paclitaxel and cisplatin.

• She is disease free at six months but longer follow-up is needed.
• PEComas refer to a family of mesenchymal tumors composed of perivascular epitheliod cells () and can range from benign to malignant ().
• PEComas have been identified in multiple anatomical sites for example liver, lung and uterus among others ().

Malignant PEComas are aggressive tumors with lack of effective therapies and most affected patients have poor prognosis (). This current study reports the first case of POD PEComa. She was treated with surgery and six cycles of doxorubicin and ifosfamide.

1. Her disease progressed despite treatment and died at one year post surgery.
2. Primary POD malignancies are rare and patients are often diagnosed with ovarian or uterine pathologies.
3. Similar to endometriotic associated ovarian cancers, the POD malignancies with concomitant endometriosis tend to be of low to moderate grade.

However more cases will need to be analyzed to verify the association. Treatment of primary POD malignancies includes primary surgery with adjuvant therapy depending on histology. With the rarer histology types, adjuvant treatment is typically based on reported cases or prior experience with the same histology types in more common sites of origin.

Carroll A., Ramirez P.T., Westin S.N., Soliman P.T., Munsell M.F., Nick A.M., Schmeler K.M., Klopp A.H., Fleming N.D. Uterine adenosarcoma: an analysis on management, outcomes, and risk factors for recurrence. Gynecol. Oncol.2014; 135 :455–461. Dockerty M.B., Pratt J.H., Decker D.G. Primary adenocarcinoma of the rectovaginal septum probably arising from endometriosis; report of two cases. Cancer.1954; 7 :893–898. Folpe A.L. Neoplasms with perivascular epithelioid cell differentiation (PEComas) In: Fletcher C.D.M., Unni K.K., Mertens F., editors. World Health Classification of Tumorspathology and Genetics of Tumors of Soft Tissue and Bone. IARC Press; Lyon: 2002.p.221. Folpe A.L., Mentzel T., Lehr H.A., Fisher C., Balzer B.L., Weiss S.W. Perivascular epithelioid cell neoplasms of soft tissue and gynecologic origin: a clinicopathologic study of 26 cases and review of the literature. Am.J. Surg. Pathol.2005; 29 :1558–1575. Huang G.S., Arend R.C., Sakaris A., Hebert T.M., Goldberg G.L. Extragenital adenosarcoma: a case report, review of the literature, and management discussion. Gynecol. Oncol.2009; 115 :472–475. Kanis M., Kesterson J.P., Shroff S., Lele S., Mhawech-Fauceglia P. Malignant mixed mullerian tumor of primary peritoneal origin. Ann. Diagn. Pathol.2011; 15 :273–277. Karateke A., Kahramanoglu I., Bilgic R. Extragenital mullerian adenosarcoma in the pouch of douglas. Balkan Med.J.2014; 31 :100–104. Kim H.S., Kim T.H., Chung H.H., Song Y.S. Risk and prognosis of ovarian cancer in women with endometriosis: a meta-analysis. Br.J. Cancer.2014; 110 :1878–1890. Ko M.-L., Jeng C.-J., Huang S.-H., Shen J., Tzeng C.-R., Chen S.-C. Primary peritoneal carcinosarcoma (malignant mixed mullerian tumor): report of a case with five-year disease free survival after surgery and chemoradiation and a review of literature. Acta Oncol.2005; 44 :756–760. Lauchlan S.C. The secondary Mullerian system. Obstet. Gynecol. Surv.1972; 27 :133–146. Naniwadekar M.R., Desai S.R., Ranade R.G., Kanetkar S.R. Extra genital heterologous malignant mixed mullerian tumor of primary peritoneal origin. Indian J. Pathol. Microbiol.2009; 52 :88–90. Selvaggi F., Risio D., Claudi R., Cianci R., Angelucci D., Pulcini D., D’Aulerio A., Legnini M., Cotellese R., Innocenti P. Malignant PEComa: a case report with emphasis on clinical and morphological criteria. BMC Surg.2011; 11 :3. Shen D.-H., Khoo U.-S., Xue W.-C., Ngan H.Y.S., Wang J.L., Liu V.W.S., Chan Y.-K., Cheung A.N.Y. Primary peritoneal malignant mixed Mullerian tumors. Cancer.2001; 91 :1052–1060. Starbuck K.D., Drake R.D., Budd G.T., Rose P.G. Treatment of advanced malignant uterine perivascular epithelioid cell tumor with mTOR inhibitors: single-institution experience and review of the literature. Anticancer Res.2016; 36 :6161–6164. Terada T. Carcinosarcoma in the pouch of douglas. Arch. Gynecol. Obstet.2010; 281 :345–348.

: Primary Pouch of Douglas malignancies: A case series and review of the literature
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What are the symptoms of pouch of Douglas?

J.S. Rajkumar 1, Jayakrishna Reddy Aluru 1*, Rajkumar Anirudh 1, Rajkumar Shreya 1, N. Manickavel 2, Sadir J. Alrawi 3 1 Lifeline Institute of Minimal Access, Chennai, India,2 ACS Medical College and Hospital, Chennai, India,3 Burjeel VPS Hospitals, Dubai, United Arab Emirates,

DOI: 10.4236/ojog.2021.116061 PDF HTML XML 99 Downloads 917 Views Abstract Introduction: This case report is one of a fairly common tumour in an extremely uncommon anatomic location. Statistically liposarcoma is the commonest type of soft issue malignancy, but publications of such a tumour arising from the pouch of Douglas (POD) to involve the uterus, are very few and far between.

Case details: A 52-year-old woman presented with a mass in the lower abdomen, post-menopausal vaginal bleeding, and lower abdominal discomfort. Investigations revealed a large pelvic tumour that was attached to the posterior wall of a bulky uterus. There was no evidence of dissemination of the tumour to distant sites, and a laparotomy was performed.

A massive soft tissue tumour occupied the POD. The tumour was dissected out from the surrounding structures, and the uterus and its appendages were removed in to. The histopathological examination revealed a liposarcoma of the pleomorphic type which was arising from the pouch of Douglas (POD), and was attached to the posterior wall of the uterus.

Extensive leiomyomatous changes were seen in the uterus. Immunohistochemistry confirmed the liposarcoma to be of pleomorphic type. Conclusion: This case report is being published for its rarity and to illuminate the specific issues in the treatment of this ubiquitous tumour in an unusual site.

The involvement of a Multidisciplinary Team (MDT) helps to choose the optimal combination of cytoreductive surgery, chemotherapy, and radiation for a given case with a POD malignancy. Share and Cite: Rajkumar, J., Aluru, J., Anirudh, R., Shreya, R., Manickavel, N. and Alrawi, S. (2021) Pouch of Douglas Liposarcoma—A Rarity.

Open Journal of Obstetrics and Gynecology, 11, 654-659. doi: 10.4236/ojog.2021.116061,1. Case Report A 52-year-old woman presented with complaints of severe lower abdominal discomfort, increasing swelling of the lower abdomen, and two episodes of vaginal bleeding in the prior two months.

• The patient was thinly built, and abdominal and vaginal examination revealed an obvious swelling in the lower abdomen that arose from the pelvis.
• Routine reports were normal and an ultrasonogram showed a large pelvic tumour, possibly of ovarian origin.
• A Contrast Enhanced CT scan ( Figure 1 ) showed a large pelvic mass with the consistency of fat which was attached to the posterior wall of the uterus.

The ovaries were imaged separately, and found to be normal. There was no regional lymphadenopathy, omental involvement or hepatic secondaries. Tumor markers for ovarian malignancies were normal. As MDT concluded on an exploratory laparotomy. Through a vertical midline incision, the abdomen and pelvis were thoroughly explored.

There were no peritoneal or liver metastases. A large solid mass occupied most of the pelvis and had infiltrated and displaced an enlarged fibroid uterus upwards against the anterior abdominal wall. ( Figure 2 ) The ovaries were normal. The operative strategy was to free the uterus from its attachments and to address the uterus and the tumour en bloc.

( Figure 3 ) A classical total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed, and the enormous tumour was removed in toto, in a macroscopic R0 resection. The vaginal vault was closed 2 cm lower than usual.1.1. Histopathology Findings Histopathological examination revealed a large leiomyomatous uterus with one area of ulceration.

In this area, the liposarcoma from the pouch of Douglas (POD) was infiltrating the uterus. The ovaries, fallopian tubes, and the rest of the uterus were free of disease. Immunohistochemistry confirmed the tumour to be a pleomorphic type of liposarcoma. The tumour showed a combination of lipogenic and non-lipogenic areas.

( Figure 4 ) There were distinct regions in the tumour that showed epitheloid features, and in two of the sectioned areas a pericytic pattern was seen. ( Figure 5 ) Tumour necrosis and vascular invasion were seen. The epithelial membrane antigen was positive, and CD 68 and CD 34 were also positive. Figure 1, Pre and Post Contrast enhanced CT showing the large pelvic tumor. Figure 2, Tumor occupying the pelvis completely 1.1. Operative procedure. Figure 3, Dissection of the tumor along with the uterus. Figure 4, HPE slide at 40 magnification showing lipogenic and non-lipogenic areas. Figure 5, HPE slide at 40 magnification showing epitheloid features and pericytic pattern.1.2. Follow-up 24 months’ follow-up: • 10 days post-op; • 2 months post-op; • 6 months post-op; • 12 months post-op (Contrast Enhanced CT Abdomen and pelvis); • 24 months post-op.2.

Discussion James Douglas, the Scottish anatomist has lent his name to this space. The Pouch of Douglas (POD) is the posterior cul-de-sac bordered posteriorly by the rectosigmoid, and anteriorly by the uterus. Its peritoneal lining originates from remnants of the Mullerian system. As the embryology is common, both benign and malignant tumours that mimic Mullerian end organs can develop here.

Another well-defined mechanism for primary POD malignancies, is the malignant transformation of endometriosis. Liposarcoma is the commonest soft tissue tumour in the human body. However, it is extremely rare in the pouch of Douglas. Only a few cases of carcinosarcoma in the Pouch of Douglas have been reported so far.

1. Primary malignancies of the POD are exceedingly rare.
2. On extensive search of current English literature by the authors, we identified around 40 cases of primary malignancies of the Pouch of Douglas.
3. The first case was reported by Dockerty et al. (1954).
4. Papillary serous carcinoma, clear cell adenocarcinoma, adenosarcoma and carcinosarcoma are some of the Mullerian types of POD malignancies.

Placenta site trophoblastic tumor, extragastrointestinal stromal tumour and malignant mesothelioma are some other tumor types that have been reported. Wong et al., concluded that there was no consensus on the optimal treatment for POD malignancies. These lesions are often diagnosed as uterine or ovarian, especially if large, as they occupy most of the pelvis.

1. Even imaging studies often fail to identify them separately.
2. The presenting symptoms almost always include abdominal pain and distention, and abnormal uterine bleeding.
3. Hence, these patients are often first seen by the gynecologist.
4. MRI or CECT helps considerably in diagnosing these lesions, as pelvic ultrasound, often done as the first modality, usually only suggests a large pelvic mass,

Despite the CT done preoperatively, this was also thought to be a uterine tumour that was occupying the pouch of Douglas. Due to the classic Hounsfield units of the fat content, the liposarcomatous nature of the neoplasm was suggested even on the pre-operative CT scan.

However, it was thought to be arising from the uterus. Histopathology and immuno histochemistry were crucial in clinching the exact diagnosis. The tumour was well circumscribed but not encapsulated, with infiltrative borders. Clumps of pleomorphic cells were found in more than 70% of the cut surface. There were distinct areas of MFH like, or spindle cell areas, as well as round cells, without a vascular network.

The tumour was of a high grade, with enlarged nuclei, with tumour necrosis and more than 25 mitotic figures seen per 10 HPF. There were focal areas of pericytic involvement, and lipoblasts present as well. IHC was positive for vimentin, S 100, CD 34, and smooth-muscle actin, and this tumour was negative for t (12; 16) (q13 p11)—T L S CHOP (more commonly seen in the myxoid variety).

• Estrogen receptor was negative.
• Pleomorphic liposarcoma of the uterus has also been reported in a patient on tamoxifen, but the tumour cells in that particular case were IHC positive for estrogen receptors apart from S 100,
• The pathological report suggested, that there was only a tiny area of secondary involvement of the uterus, pointing towards a primary POD malignancy that had secondarily infiltrated the uterus.

There was no concurrent endometriosis seen on the histology, a well-known source of a pouch of Douglas neoplasm. In most of the cases, patients undergo cytoreductive surgery, which was considered by the authors to be optimal in this case. In view of the size of the tumour, the MDT recommended concurrent radiation as well as polycyclic chemotherapy and these were instituted.

1. With an overall 39% survival rate for pleomorphic liposarcoma, and with the grade of this tumour being higher in this case, we are guarded in the prognosis for this patient.
2. However, at the time of publication, about two years post-surgery, she seems to be free of disease, clinically and radiologically.3.

Conclusion Although liposarcomas are found everywhere, pouch of Douglas liposarcomas are a rarity. A pleomorphic type of liposarcoma, confirmed by immunohistochemistry, arising from the Pouch of Douglas, has its specific set of challenges, in diagnosis as well as treatment.
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Can pouch of Douglas prevent pregnancy?

Endometriosis and fertility – Many women with endometriosis have no problem with their fertility and are able to get pregnant easily and naturally. Some women with endometriosis do experience difficulty conceiving. The effects of endometriosis on fertility are individual to each woman.

• The build-up of scar tissue (also referred to as adhesions) caused by endometriosis can affect the ovaries and the fallopian tubes.
• Scar tissue can stick to these organs, causing them to twist, narrow or change shape.
• It can also cause the pelvic organs to become ‘sticky’ and cause them to fuse together.

This can lead to problems with fertility by physically preventing the ovaries from releasing an egg each month. If an egg is released, scar tissue on the fallopian tubes can prevent the egg from travelling to the uterus (womb) and prevent fertilisation.

It can also prevent the sperm reaching the egg. The Pouch of Douglas is an area within the pelvis behind your uterus where the ovaries and fallopian tubes sit. Endometriosis can cause adhesions and scar tissue in this area which can also cause fertility problems as well as pain with intercourse and opening your bowels.

Some women with mild endometriosis experience fertility problems and some women with severe endometriosis experience no problems conceiving. Difficulty falling pregnant is more common however, in women with moderate to severe endometriosis. The exact reason why endometriosis causes fertility problems in some women and not others is unclear.
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Why is the pouch of Douglas important?

What Are the Uses of the Pouch of Douglas? – The pouch of Douglas is a good site for peritoneal dialysis, making it invaluable in patients with end-stage renal failure. A catheter called the Tenckhoff catheter is placed in the pouch (specifically the distal end) and may even be sutured to the bladder.

1. This helps prevent the migration of the bladder.
2. Conclusion: By itself, the pouch of Douglas is simply an anatomical structure that displays some fluid collection throughout the course of a woman’s menstrual cycle (or during her childbearing years).
3. However, it should be noted that the pouch of Douglas is a central area or location for seeded lesions due to its dependency when upright or supine.

Most cases of pouch of Douglas pathologies are treatable, and malignancies occur very rarely, making this an area of interest but not a cause for excessive concern. Last reviewed at: 01 Aug 2022 – 5 min read
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How pouch of Douglas is formed?

Rectouterine pouch
Sagittal section of the lower part of a female trunk, right segment. (Excavatio recto-uterina labeled at bottom right.)
Median sagittal section of female pelvis. (Rectouterine excavation labeled at center left.)
Details
Identifiers
Latin	excavatio rectouterina, cavum douglassi, fossa douglasi
MeSH	D004312
TA98	A10.1.02.512F
TA2	3726
FMA	14728
Anatomical terminology

The rectouterine pouch ( recto-uterine pouch ), pouch of Douglas, or rectovaginal pouch is the extension of the peritoneum between the rectum and the posterior wall of the uterus in the human female. Its anterior boundary is formed by the posterior fornix of the vagina,
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What is the meaning of pouch of Douglas?

Pouch of Douglas: An extension of the peritoneal cavity between the rectum and the back wall of the uterus. Also known as the rectouterine pouch,
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Can the pouch of Douglas be removed?

It seems to the editor that the uterosacral ligaments and pouch of Douglas are seldom removed when hysterectomy is performed in the type of cases reported in this paper; one achieves mobility of the uterus before its removal by cutting the uterosacral ligaments, not removing them; in these cases we are concerned about
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What is another name for the pouch of Douglas?

Citation, DOI & article data – Citation: Vasu B, Weerakkody Y, Agolah D, et al. Rectouterine pouch. Reference article, Radiopaedia.org (Accessed on 29 Dec 2022) https://doi.org/10.53347/rID-27118 The rectouterine pouch ( TA : excavatio rectouterina 3 ), also known as the rectovaginal pouch, cul-de-sac or pouch of Douglas, is an extension of peritoneum between the posterior wall of uterus and the rectum in females.
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Does pouch of Douglas contain fluid?

Anatomy – The pouch of Douglas (recto-uterine pouch) is formed by reflection of the peritoneum between the rectum posteriorly and the posterior surface of the uterus anteriorly. The pouch often contains small intestine and a small amount of peritoneal fluid.
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Does fluid in the pouch of Douglas cause pain?

Summary – Two small pouches called cul-de-sacs are located on either side of the uterus. Fluid sometimes builds up in these pouches. A little fluid is normal, but if it contains pus or blood, or if it’s causing pain, there may be a bigger health problem.

Infection, pregnancy complications, or health conditions such as endometriosis or fibroids could be the cause. It’s also possible that a cyst, a follicle, or the uterus itself has ruptured. In some cases, fertility treatment can cause the extra fluid. An ultrasound can usually detect the fluid. You may also need a culdocentesis, where a sample of the fluid is drawn out with a needle so it can be tested.

ectopic pregnancy in pouch of douglas

Depending on the cause, the fluid may need to be drained or treated with antibiotics.
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How deep is the pouch of Douglas?

The rectouterine pouch (of Douglas) is created by the reflection of peritoneum from the anterior rectal wall ventrally onto the posterior surface of the uterus and upper vagina, with the base of the pouch approximately 5 to 7.5 cm from the anal verge in women. From: Posterior Pelvic Floor Abnormalities, 2011
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Who is the pouch of Douglas named after?

Abstract – James Douglas (1675-1742) is considered one of the most important anatomists of the eighteenth century; he introduced meticulous and scientific methods for studying human anatomy. He is known for the “pouch of Douglas,” but his contribution is much more important.
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What prevents pregnancy for up to 3 years?

What Is Implantable Contraception? – Implantable contraception (often called the birth control implant ) is a small, flexible plastic tube that doctors put under the skin of the upper arm. The tube releases hormones that can help protect against pregnancy for up to 3 years.
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What does pouch of Douglas mean?

Pouch of Douglas: An extension of the peritoneal cavity between the rectum and the back wall of the uterus. Also known as the rectouterine pouch,
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Is pouch of Douglas supposed to be empty?

A small amount of fluid in the pouch of douglas is normal and is usually not of concern. If the fluid sample shows signs of pus or blood, the area may need to be drained.
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Can the pouch of Douglas be removed?

It seems to the editor that the uterosacral ligaments and pouch of Douglas are seldom removed when hysterectomy is performed in the type of cases reported in this paper; one achieves mobility of the uterus before its removal by cutting the uterosacral ligaments, not removing them; in these cases we are concerned about
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How pouch of Douglas is formed?

Rectouterine pouch
Sagittal section of the lower part of a female trunk, right segment. (Excavatio recto-uterina labeled at bottom right.)
Median sagittal section of female pelvis. (Rectouterine excavation labeled at center left.)
Details
Identifiers
Latin	excavatio rectouterina, cavum douglassi, fossa douglasi
MeSH	D004312
TA98	A10.1.02.512F
TA2	3726
FMA	14728
Anatomical terminology

The rectouterine pouch ( recto-uterine pouch ), pouch of Douglas, or rectovaginal pouch is the extension of the peritoneum between the rectum and the posterior wall of the uterus in the human female. Its anterior boundary is formed by the posterior fornix of the vagina,
View complete answer