Endometriosis can occur in different areas of the body, including the cul-de-sac, which people also refer to as the rectouterine pouch, or the pouch of Douglas.

The cul-de-sac is located between the rectum and the back of the uterus.

Endometriosis most often occurs in the ovaries, but also commonly affects the cul-de-sac. This type of endometriosis may be difficult to diagnose and treat.

The condition can cause pain, bleeding, and other symptoms, and may lead to complications.

This article looks at the symptoms, diagnosis, treatment, and outlook for cul-de-sac endometriosis.

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Endometriosis is a condition in which tissue similar to the inner lining of the uterus grows outside the uterus. The tissue can grow anywhere in the body but typically forms in the pelvis.

Endometriosis most often affects the ovaries, but it can also affect areas including the posterior cul-de-sac, between the uterus and the rectum, and the anterior cul-de-sac, between the bladder and the uterus.

Posterior cul-de-sac endometriosis is the more common of the two and accounts for up to 37% of cases of endometriosis.

Endometriosis in the posterior cul-de-sac is more likely to be symptomatic and carries a higher risk of deeply infiltrative endometriosis (DIE) than the condition in other regions.

DIE is an aggressive form of endometriosis that can cause severe symptoms. It may lead to serious health complications, such as a frozen pelvis. This means scar tissue adheres organs in the pelvis together, ‘freezing’ them in place. The distortion of the organs can lead to further complications.

The severity of a person’s symptoms does not always indicate the severity level of the disease.

Symptoms can differ between individuals, although people often describe pain from endometriosis as cyclic and progressively worse over time.

The symptoms of cul-de-sac endometriosis can include:

There is usually a delay of 4 to 11 years between the onset and the diagnosis of endometriosis.

It can be difficult for a doctor to diagnose endometriosis, as symptoms of the disease may be similar to those of various other gynecological and gastric conditions. There are no specific tests to diagnose the disease.

Doctors may find it even more challenging to diagnose cul-de-sac endometriosis. Diagnosis of endometriosis typically involves a laparoscopy. However, the location of the cul-de-sac means it is inaccessible by laparoscopy. A doctor may, therefore, have to rely on MRI scans, pelvic examination, and biopsies to diagnose the disease.

There is currently no cure for endometriosis, but treatment can help relieve the symptoms.

Treatments for endometriosis typically involve medication for the symptoms of the disease, as well as surgery.

Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) can help relieve pain, and hormonal birth control medication can help slow the progression of the disease.

A person may require surgery to remove the excess tissue and scar tissue in the pelvis.

Endometriosis is a chronic disease. However, people may be able to manage the symptoms and slow the progression of the disease with treatment.

People with endometriosis have a lower chance of childbearing and a higher risk of experiencing an ectopic pregnancy or miscarriage than those without the disease.

Evidence varies on the recurrence of endometriosis after surgery, and different estimates indicate rates of 6% to 67%. Treatment can help a person manage the symptoms; however, pain persists in 5% to 59% of people after therapy.

Complications from cul-de-sac endometriosis and surgery to treat the disease may affect a person’s quality of life. These can include infertility, bladder and bowel dysfunction, and chronic pain.

The National Institutes of Health (NIH) provides a list of organizations that offer information and resources about endometriosis, including:

  • Endometriosis.org: An organization that provides information on treatments and mental health support for people with endometriosis.
  • Womenshealth.gov: The Office on Women’s Health promotes health equity and provides information on female health topics.
  • American College of Obstetricians and Gynecologists: An organization of gynecologists, obstetricians, and other healthcare professionals who provide healthcare for females.

Online and in-person endometriosis support groups are available that provide a space for people to share experiences and offer support. These include:

  • The Endo Co Patient Support Group: This online support group usually meets monthly to help people learn coping strategies and share their experiences.
  • Endo Warriors: An organization that offers in-person and online support groups for people with endometriosis.
  • Endo Black, Inc: Offers a safe space for Black females and females of color with endometriosis to connect and support each other.
  • endoQueer: This organization offers resources to LGBTQIA+ people with endometriosis, including hotlines, community groups, and a Facebook group where they can connect.

Below are the answers to some frequently asked questions about cul-de-sac endometriosis.

What is an endometriosis cul-de-sac?

An endometriosis cul-de-sac refers to the growth of endometrium-like tissue in the cul-de-sac, a pouch of space between the uterus and the rectum.

Does free fluid in the cul-de-sac mean endometriosis?

A small amount of free fluid in the cul-de-sac is normal. A healthcare professional may test a sample of the fluid to determine if it indicates a health problem.

What does cul-de-sac mean in ultrasound?

During an ultrasound or imaging scan, healthcare professionals will check the cul-de-sac for signs of fibrous tethers and lesions that can indicate endometriosis or deeply infiltrative endometriosis (DIE).

Cul-de-sac endometriosis involves the growth of endometrial-like tissue in the cul-de-sac, an area between the rectum and the bladder. The disease is often severe and difficult to diagnose and can lead to health complications.

Symptoms of cul-de-sac endometriosis typically involve pelvic pain, menstrual cramps, and difficulty passing stool. Complications can include fibrous tissue tethering organs, which distorts them and freezes them in place.

Treatment can help a person manage the symptoms and slow the progression of the disease. Therapies for endometriosis typically involve medication, and surgery to remove unwanted tissue.