OBJECTIVE As an alternative to traditional surgical transrectal and transgluteal drainage, we have examined the efficacy of transrectal sonographically guided drainage for deep pelvic abscesses not accessible by percutaneous transabdominal or transvaginal routes. METHODS In nine patients (five males and four females) 5-51 years old, sonography or CT showed pelvic abscesses that were deemed unapproachable by percutaneous transabdominal or transvaginal routes because of interposed bowel (five patients), presacral location (two patients), or inability of the pediatric vagina to accommodate a transvaginal probe (one patient). One patient refused both transvaginal and transgluteal routes in preference to transrectal drainage. IV sedation (adults) or general anesthesia (children) was used for all drainages. A 7.5-MHz end-fire transrectal sonographic probe fitted with a biopsy guide was inserted into the rectum, and the collection was localized. With sonographic guidance, an 18-gauge needle and then a guidewire were advanced into the collection. Then with fluoroscopic guidance, a self-retaining drainage catheter was placed by using the Seldinger technique. RESULTS All nine collections were successfully accessed and effectively drained without complication. Catheters were removed after 1-24 days (mean, 7 days; median, 5 days) without recurrent abscesses. CONCLUSIONS Transrectal sonographically guided drainage of deep pelvic abscesses is a safe, well-tolerated, effective alternative to the more traditional surgical transrectal drainage or transgluteal approach, especially in pelvic abscesses that cannot be safely drained via a percutaneous transabdominal or transvaginal route.