RECTOUTERINE POUCH
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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.
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The pouch often contains small intestine and a small amount of peritoneal fluid.
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It is the most dependent intraperitoneal space in both the upright and the supine position.
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Blood, pus, and other free fluids in the peritoneal cavity pool in the pouch because of its dependent location.
Culdocentesis
Culdocentesis involves the extraction of fluid from the rectouterine pouch (pouch of Douglas) through a needle inserted through the posterior fornix of the vagina. It can be used to extract fluid from the peritoneal cavity or to drain a pelvic abscess in the rectouterine pouch.
Abnormal Positioning of the Uterus
In some individuals, the uterus may not lie in an anteflexed
and anteverted position. The common abnormal
dispositions are:
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Retroverted and anteflexed
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Retrovertd and retroflexed
These abnormal positionings do not inherently cause any
medical problems. However, the retroverted uterus is
positioned directly above the vagina. Thus in instances of
increased abdominal pressure, the uterus is more likely
toprolapse into the vagina.
* Uterine prolapse is particularly prevalent in those with a
history of pelvic floor damage.
Hysterectomy
Hysterectomy is the surgical removal of the uterus, usually as a result of cervical or uterine cancer.
When performing a hysterectomy, a good knowledge of regional anatomy is needed to prevent accidentally damaging
other structures in the pelvic region. The uterine artery crosses the ureters approximately 1 cm laterally to the internal
os. Care must be taken not to damage the ureters during clamping of the uterine arteries during hysterectomy. The
relationship between the two can be remembered using the phrase ‘water under the bridge’. Water refers to the ureter
(urine), and the uterine artery is the bridge.
Disorders of the Endometrium
Endometriosis is the presence of ectopic endometrial tissue at sites outside the uterus, most commonly the ovaries and
the ligaments of the uterus. Ectopic tissue is responsive to oestrogenic stimuli therefore cyclic proliferation and bleeding
occur, often forming a cyst. The condition is associated with dysmenorrhoea and/or infertility.
Fibroids are benign tumours of the endometrium. Most fibroids are asymptomatic, but if large enough can cause
symptoms including menorrhagia, pelvic pain and infertility.
Endometrial Carcinoma is the commonest malignancy of the female genital tract, most often found during, or after, the
menopause, and characterised by abnormal uterine bleeding. The majority of neoplasms are found in the transformation
zone of the cervix between the columnar epithelium of the endocervix and the stratified squamous epithelium of the
exocervix.
Cervicitis
Cervicitis is chronic inflammation and infection of the cervix. It is usually asymptomatic although pelvic pain, vaginal
discharge, may be present. Complications of cervicitis include t the potential blockage of mucus ducts and cyst formation
which increases the risk of infertility by increasing the hostility of the environment for sperm.
Cervical Cancer
Cancer of the cervix the most common cancer affecting the female reproductive tract. There are two main types of
cervical cancer:
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Squamous cell carcinoma – cancer of the epithelial lining of the ectocervix.
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Adenocarcinoma – cancer of the glands found within the lining of the cervix.
* Infection of the female genitalia with human papilloma virus (HPV), is widely known as the cause of the majority
of cervical cancers. Latest vaccinations against cervical cancer are, in essence, a vaccination against HPV.
Vaginal Fistulae
A fistula occurs when there is a open communication between the vagina and one of the adjacent pelvic organs.
There are three main types of vaginal fistulae:
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Vesicovaginal – Between the vagina and the bladder. Urine enters the vagina constantly.
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Urethrovaginal - Between the vagina and the urethra. Urine only enters the vagina during urination.
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Rectovagina – Between the vagina the rectum. Fecal matter can enter the vagina is this type of fistula
A vaginal fistula usually occurs as a result of a long and traumatic childbirth, where a caesarian section is not
available. As the foetus slowly progresses down the vaginal wall, it cuts off the blood supply, and necrosis results.