Fluid in Anterior or Posterior Cul-de-Sac

By
Nicole Galan, RN

Nicole Galan, RN, is a registered nurse and the author of "The Everything Fertility Book."

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Nicole Galan, RN
Medically reviewed by
Medically reviewed by Anita Sadaty, MD on October 17, 2020

Anita Sadaty, MD, is board-certified in obstetrics-gynecology. She is a clinical assistant professor at Hofstra Northwell School of Medicine and founder of Redefining Health Medical.

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Anita Sadaty, MD
on October 17, 2020

Your gynecologist or fertility specialist may report that an ultrasound has detected free fluid in your cul-de-sac area. This is an area just behind the vagina. Learn the different causes and concerns about this finding.

Cul-de-Sac Anatomy

There are two small pouches close to the uterus, one on either side, called the cul-de-sacs. The anterior cul-de-sac is located between the bladder and the uterus. The posterior cul-de-sac is found between the uterus and the rectum.

They are also called the excavatio recto-uterina (posterior) and excavatio vesico-uterina (anterior). Another term for cul-de-sacs is pouch of Douglas, named after the Scottish anatomist James Douglas. 

Causes of Fluid in Cul-de-Sac

Fluid in the cul-de-sac can be caused by many different factors. Sometimes fluid from a ruptured cyst or follicle can accumulate there. At other times, fluid in the cul-de-sac could indicate more severe problems. Here are some possible causes of fluid in the cul-de-sac:

Finding in Fertility Treatment

In women undergoing fertility treatment, fluid in the cul-de-sac (as seen on ultrasound) is a common finding in ovarian hyperstimulation syndrome (OHSS).

If your doctor suspects that you have this condition, they will likely suggest that you have an ultrasound to check for fluid and measure your ovaries, as enlarged ovaries are also common in OHSS.

Usually, fluid in the cul-de-sac is not a cause for alarm but could be causing discomfort and affecting your fertility.

Diagnostic Testing

Transvaginal ultrasound is the procedure that is used to show whether there is fluid behind the uterus. Fluid will show up well on ultrasound. If fluid is found in your cul-de-sac and you are experiencing pain, your doctor may order more advanced testing of the fluid.

Culdocentesis is a procedure performed to check any abnormal fluid in the cul-de-sac area. Before transvaginal ultrasound became widely available, it was also used to detect the fluid. Now, it is used to remove fluid to evaluate.

Culdocentesis involves inserting a needle through the vaginal wall to draw off a sample of fluid to analyze. A numbing agent or anesthesia may be used prior to the procedure. You will have a pelvic exam and your health care provider will hold the cervix with an instrument to insert the needle in the correct place.

A small amount of fluid in the cul-de-sac 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. Sometimes blood can be a result of ruptured cyst or signs of an ectopic pregnancy.

The presence of pus could indicate an infection caused by a tear or other conditions. The blood would need to be drained and antibiotics used to treat the infection.

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  1. Revzin MV, Mathur M, Dave HB, Macer ML, Spektor M. Pelvic inflammatory disease: multimodality imaging approach with clinical-pathologic correlation. Radiographics. 2016;36(5):1579-96. doi:10.1148/rg.2016150202

  2. Kumar P, Sait SF, Sharma A, Kumar M. Ovarian hyperstimulation syndrome. J Hum Reprod Sci. 2011;4(2):70–75. doi:10.4103/0974-1208.86080

  3. UCSF Health. Culdocentesis.

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