CULDOCENTESIS

DEFINITION
Cul- de- sac- the Pouch of Douglas
Centesis- a suffix, means, puncturing
of a body cavity or organ, with a
hollow needle to draw out fluid.
Culdocentesis -procedure involving
extraction of peritoneal fluid from the
rectouterine Pouch of Douglas via a
spinal needle.

INDICATIONS
Diagnosis of suspected leaking or
ruptured ectopic pregnancy when
ultrasonography and laparoscopy is
not immediately available.
Detection of haemaperitonium
following blunt abdominal trauma.
Obtaining of fluid for culture to aid in
diagnosis and treatment of Pelvic
Inflammatory Disease.

CONTRAINDICATIONS
Presence of a pelvic mass, posterior to the
Cul- de- Sac, that might contaminate the
peritoneal cavity if perforated or that could
impede access to free fluid in the Pouch.
A fixed retroverted uterus.
Bleeding diathesis.
Pre- pubescence because of the anatomy;
the vagina is normally smaller.
Non- cooperative patient.

PROCEDURE
Informed consent has to be obtained from the patient before the procedure.
The patient also has to be asked to either walk around, or sit for up to 15 minutes, to
allow the fluid to pool to the Pouch of Douglas.
Steps.
Place the patient into the dorsal lithotomy position with the head of the examining
table elevated at 60 degrees to allow pooling of peritoneal fluid in the posterior cul- desac.
Expose the posterior vaginal fornix with the bi-valve vaginal speculum.
Cleanse the vagina and cervix with antiseptic.
Apply/ inject anesthetic into vaginal mucosa of the posterior fornix in the midline
approximately 1 cm inferior to the point at which the posterior vaginal wall joins the
cervix.
Grasp the posterior lip of the cervix using the tenaculum and lift the cervix slightly to
expose the posterior fornix; bounded laterally by the uterosacral ligaments.
Insert the 18 gauge needle attached to a 20ml syringe containing 5ml of air through
the posterior vaginal wall into the Pouch using a rapid deliberate thrust. The needle
should not extend more than 4cm through the vaginal mucosa and is directed caudad,
away from the uterus and toward the sacrum.
Aspirate peritoneal fluid, and then remove the needle slowly. If no fluid is obtained,
repeat the procedure at a different angle with a new needle, as a dry tap is considered
unsatisfactory. Discontinue the procedure if unsuccessful after two or three attempts.

INTERPRETATION OF RESULTS.
Color

Significance

Clear to straw colored fluid.

Normal.

More than 2mls of non-clotting blood.

Raptured ectopic pregnancy.

Hemorrhage from a corpus luteum cyst.
Retrograde menstruation.
Acute salpingitis.
Raptured spleen, or liver.
Raptured ovarian cyst.
Gastrointestinal bleed

NB: The blood is non-clotting because, fibrinolysis

occurred after the initial clotting.
If the blood clots, then one should consider the
possibility of a punctured vessel in the wall of the
vagina.

More than 10 ml of clear fluid.

Ruptured ovarian cyst

Ascites.
With a histological presence of malignant cellscarcinoma.

NB: A clear fluid does not rule out ectopic

pregnancy as it may exist with another pathology.

Dark brown fluid.

Old blood as in the case of

Raptured endometrial cyst, chronic ectopic
pregnancy.

Purulent.

Pelvic inflammatory disease.

Acute salpingitis.
Raptured tuboovarian abscess.
Raptured diverticular abscess.
Uterine abscess with myoma.
Raptured appendix or viscus.
Appendicitis, Diverticulitis.

Greasy/ Fatty.

Raptured teratoma.

Cloudy.

Pelvic peritonitis.
Twisted adnexal cyst.

Dry tap.

Unsatisfactory. Repeat culdocentesis.

ADVANTAGES.
It takes a shorter time; appropriate
for emergency situations.
It is safe, as it does not expose the
patient to electromagnetic waves.
It is very simple to perform.

DISADVANTAGES.
It is invasive.
Rapture of of a tubal pregnancy, or
unsuspected tubo ovarian abscess may
occur, leading to pelvic peritonitis.
Puncture of the bowel or pelvic kidney.
Extensive bleeding may occur as the
vaginal muscle is highly vascularized.
Needle injury to an intrauterine
pregnancy in a retroverted uterus.

OTHER METHODS OF DIAGNOSIS OF OVARIAN CANCER.

A thorough history
On examination, one may discover a
fixed, hard, irregular abdominal mass
from the pelvis
Necessary tests include;
A full haemogram- which would indicate
a reduction in Hb. (N: 12- 16 g-dL)
Urea and electrolytes.
Liver function tests.

 Important imaging techniques will

include;
Ultrasonography which would
indicate the presence and features of
the adnexal mass. It will also aid in
differentiating between a Benign and
Malignant mass.

 Color flow Doppler studies to evaluate vascular patterns

of adnexal masses; an improvement of benign and
malignant lesions.
Chest radiograph to indicate metastatic parenchymal
disease, and pleural effusion.
Characterization of the adnexal masses by
Computerized tomography (provides information on
retroperitoneal structures and pelvic organs) and
Magnetic Resonance Imaging (provides information on
the nature of the ovarian neoplasm).
Barium enema or colonoscopy- to differentiate between
ovarian and colonic tumors. Bowel movement must also
be assessed.

 Biological markers will include;

CA- 125 -cancer antigen 125 is a secreted glycoprotein present
in foetal amniotic and coelomic epithelium whose level is
detected by immunoassay. The accepted upper limit of normal is
35 IU/mL. It is especially important in postmenopausal women.
Serum Alfa fetoprotein and Lactate dehydrogenase. The levels
will be raised. These are particularly important in young girls
with adnexal masses.

Other methods include;
Diagnostic thoracocentesis for cytology and staging. If there's a
presence of malignant pleural effusion, the patient is likely in
Stage IV disease.

REFERENCE.
Current Diagnosis and Treatment, Obstetrics and
Gynaecology; 11th Edition. Page 245, 569, 570.
Current Diagnosis and Treatment, Obstetrics and
Gynaecology; 1987. Page 265, 556, 712, 784.
Novak's Gynaecology; 13th Edition. Page 98,
522.
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emedicine.medscape.com/article/83097overview