Abscess of Douglas space is an encapsulated purulent focus located in the utero-rectal (rectal-vesicular) recess of the pelvis. The clinic is characterized by nonspecific manifestations (intoxication, febrile fever, chills) and local symptoms (pain in the lower abdomen, dysuric phenomena, frequent urge to defecate). Diagnosis includes rectal and vaginal (in women) examination, pelvic ultrasound, CT, puncture of the abscess through the rectum or posterior vaginal arch. Treatment of the Douglas space abscess consists in opening it through the rectum or vagina, drainage and sanitation, and antibiotic therapy.
K65.0 Acute peritonitis
According to specialists in the field of gynecology and general surgery, Douglas space abscess occurs in 1-3% of cases (in 0.06-0.11% – after surgical interventions). Douglas space abscess is a fairly common type of abdominal abscesses. An encapsulated abscess with this type of abscess is formed in the utero-rectal recess in women and the rectal-vesicular recess in men.
Causes of Douglas space abscess
In most cases, an abscess of the Douglas space develops against the background of a destructive form of acute appendicitis (phlegmonous, gangrenous, perforated) with a pelvic location of the vermiform process. In women, purulent diseases of the appendages (adnexitis, pyosalpinx) can lead to the formation of a pelvic abscess. Less often, the occurrence of an abscess of the Douglas space is preceded by perforation of the diverticulum of the colon, paraproctitis, diffuse forms of peritonitis.
The pyogenic microflora is represented by non-specific pathogens (staphylococci, intestinal and paracystic coli, streptococci, Pseudomonas aeruginosa, etc.). The formation of this disease is facilitated by a decrease in the reactivity of the organism and an increase in the virulence of pathogenic microflora.
The abscess of Douglas space is always formed a second time. The flow of blood, serous or purulent effusion into the Douglas space is facilitated by the anatomical features of the pelvis, where mesenteric sinuses and channels open. With insufficiently thorough revision and toilet of the operating wound, inadequate drainage 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.
Symptoms of Douglas space abscess
The organization of this disease, as a rule, occurs 5-10 days after surgery for a primary purulent disease. First of all, there are general nonspecific symptoms characterized by the sudden development of chills, an increase in body temperature to febrile values, tachycardia, nausea, headache. Against this background, there are sensations of bursting and sharp pains in the lower abdomen, which increase when walking, movements, and physiological functions. With an abscess of the Douglas space, patients may be disturbed by frequent and painful urination, tenesmus, loose stools with an admixture of mucus and blood, incontinence of gases and feces.
Extensive abscesses of the Douglas space, surrounded by a massive infiltrate, sometimes lead to compression of the rectum, causing mechanical intestinal obstruction. The progression of pathology 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 pelvic abscess leads to the development of pelvic vein thrombophlebitis and thromboembolic disease.
During the consultation of a gastroenterologist, an anamnesis is collected. The specialist pays attention to recently undergone operations and diseases, which makes it possible to suspect the probability of an abscess.
Palpation is determined by soreness in the pelvic region, local muscle tension, a positive symptom of Shchetkin – Blumberg. Rectal or vaginal examination reveals a painful tugoelastic infiltrate with softening and fluctuation in the center. In women, the abscess of the Douglas space is palpated above the cervix, the overhang of the posterior vaginal arch is determined.
For differential diagnosis with tubovarial abscess in women, ultrasound of the pelvis is performed; to exclude prostate abscess in men, ultrasound of the prostate is performed.
In difficult differentiable cases, it may be necessary to perform computed tomography, MRI. For the final recognition of the abscess of the Douglas space, diagnostic puncture of the abscess is resorted to under ultrasound guidance through the rectum or the posterior arch of the vagina. The resulting purulent contents are subjected to bacteriological examination.
Treatment of Douglas space abscess
Microclysms and antibiotics are prescribed at the infiltrative stage; after the final formation of the abscess, which is judged by the softening of the infiltrate and the appearance of fluctuation, the abscess is opened. Abscesses are opened through the wall of the rectum or through the posterior arch of the vagina. First, the puncture of the abscess is performed with a thick needle.
After receiving pus, to ensure its free outflow from the cavity of the abscess, the hole is dissected along the needle, expands in a blunt way, and a two-light drainage (or a catheter with a swollen cuff) is installed in it. Postoperative sanitation of the purulent cavity is carried out.
A posterior colpotomy can be used to open in women. If it is impossible to open the abscess transerctally or transvaginally, operative access in the iliac region is used, followed by the introduction of drainage into the pelvis.
Prognosis and prevention
With a single abscess and timely intervention, the outcome of the disease is favorable – recovery occurs. Complications of the Douglas space abscess can develop when the abscess breaks into the abdominal cavity or adjacent organs.
Prevention requires adequate revision and sanitation of the abdominal cavity during surgical interventions, thorough stopping of bleeding, timely treatment of purulent tubovarial formations and paraproctitis. After a complicated appendectomy in the postoperative period, a systematic vaginal or rectal examination is necessary for timely recognition of the Douglas space abscess.