Douglas pouch abscess: infection of the Douglas space
Abscess of the Douglas space is an encapsulated purulent focus located in the utero-rectum (rectal-vesicular) deepening of the pelvis. The clinic of the abscess of the Douglas pouch is characterized by nonspecific manifestations (intoxication, febrile temperature, chills) and local symptoms (pain in the lower abdomen, dysuric phenomena, frequent urges for defecation).
Diagnosis of small pelvis abscess includes rectal and vaginal (in women) study, ultrasound of the small pelvis, CT, puncture of the abscess through the rectum or posterior vaginal vault. Treatment of the abscess of the Douglas pouch consists in its opening through the rectum or vagina, drainage and sanitation, and antibiotic therapy.
According to general surgery, gynecology and operative gastroenterology, abscess of the Douglas pouch occurs in 1-3% of cases (in 0,06-0,11% – after surgical interventions).
The abscess of the Douglas space is a fairly common type of abdominal abscess. Encapsulated abscess with this type of abscess is formed in the utero-rectum groove in women and rectal-vesicle – in men.
Causes of abscess of the Douglas space
Abscesses of the small pelvis are always secondary. In most cases, the abscess of the Douglas pouch develops against the background of the destructive form of acute appendicitis (phlegmonous, gangrenous, perforative) in the pelvic position of the appendix. In women, purulent diseases of the appendages (adnexitis, pyosalpinx) can lead to the formation of an abscess of the small pelvis. Less often the abscess of the Douglas space is preceded by perforation of the diverticulum of the colon, paraproctitis, diffuse forms of peritonitis.
Blood flow, serous or purulent effusion into the Douglas space is facilitated by the anatomical features of the small pelvis, which opens the mesenteric sinuses and canals. With insufficient revision and toilet of the operating wound, inadequate draining and sanitation of the pelvis in the deepest place of the abdominal cavity – the douglas space, conditions are created for the formation of an abscess.
The pyogenic microflora is represented by nonspecific pathogens (staphylococci, intestinal and parakishechnoy rod, streptococci, Pseudomonas aeruginosa, etc.). The formation of the abscess of the Douglas space is facilitated by a decrease in the reactivity of the organism and an increase in the virulence of the pathogenic microflora.
Symptoms of Douglas pouch abscess
Organization of the abscess of the Douglas space, as a rule, occurs 5-10 days after the operation for the primary purulent disease. First of all, there are general nonspecific symptoms, characterized by sudden development of chills, fever, febrile values, tachycardia, nausea, headache.
Against this backdrop, there are sensations of bursting and sharp pains in the lower abdomen, which increase with walking, movements, and physiological functions.
In the abscess of the Douglas space, patients may be prone to frequent and painful urination, tenesmus, loose stools with an admixture of mucus and blood, incontinence of gases and stool. Extensive abscesses, surrounded by a massive infiltration, sometimes lead to compression of the rectum, causing mechanical intestinal obstruction.
Further progression of the abscess of the Douglas pouch can be complicated by the breakthrough of the abscess into the free abdominal cavity or hollow organs – the bladder, uterus, rectum. A prolonged course of the pelvic abscess leads to the development of thrombophlebitis of pelvic veins and thromboembolic disease.
Diagnosis of Douglas pouch abscess
When collecting anamnestic data, recently transferred operations and diseases are taken into account, which allows one to suspect the probability of an abscess of the Douglas space. Palpation is determined by soreness in the pelvic region, local muscle tension, a positive symptom of Shchetkin-Blumberg.
When a rectal or vaginal examination reveals a painful tugoelastic infiltration with softening and fluctuating in the center. In women, the abscess of the Douglas space is palpated above the cervix, and the hanging of the posterior vaginal fornix is determined.
For differential diagnosis with a tubo-ovarian abscess, women undergo pelvic ultrasound; for the exclusion of prostatic abscess in men – ultrasound of the prostate. In difficult to differentiate cases, computed tomography may be required.
For the final recognition of the abscess of the Douglas pouch, a diagnostic puncture of the abscess is performed under ultrasound guidance through the rectum or posterior vaginal fornix. The purulent contents obtained are subjected to bacteriological examination.
Treatment of the Douglas pouch abscess
At the infiltrative stage, microclysters and antibiotics are prescribed; after the final formation of the abscess, which is judged by the softening of the infiltrate and the appearance of fluctuations, the abscess is opened.
Abscesses of the Douglas space are opened through the wall of the rectum or through the posterior vaginal fornix. First, the needle is punctured with a thick needle.
After receiving pus, to ensure its free outflow from the cavity of the abscess, the hole along the needle is dissected, dilated bluntly, and it installs a double-lumen drainage (or catheter with a swollen cuff). Postoperative sanation of the purulent cavity is performed.
To open the abscess of the Douglas space in women, posterior colpotomy can be used. If it is not possible to open the abscess transectally or transvaginally, operative access in the ileum region is used, followed by the introduction of drainage into the small pelvis.
Prognosis and prevention of the Douglas pouch abscess
With a single abscess of the Douglas space and timely intervention, the outcome of the disease is favorable – recovery occurs. Complications of the abscess of the Douglas space can develop when an abscess breaks into the abdominal cavity or adjacent organs.
Prevention of abscess of the Douglas space requires adequate revision and sanation of the abdominal cavity during surgical interventions, careful stop of bleeding, timely treatment of purulent tubo-ovarian formations and paraproctitis. After a complicated appendectomy in the postoperative period, a systematic vaginal or rectal examination is needed to timely recognize the abscess of the Douglas space.