Should I return to the ER immediately for evaluation of potential ovarian torsion or rupture given severe pelvic pain and vomiting with a history of Von Willebrand's disease and total hysterectomy?

Immediate ER Evaluation Required for Suspected Ovarian Complication

You should return to the emergency department immediately—your constellation of severe unremitting pain (9-10/10), vomiting, inability to sleep, difficulty urinating, and a rapidly enlarging ovarian cyst (3.2 cm to 4.7 cm in 4 days) in the setting of Von Willebrand disease represents a gynecologic emergency that requires urgent imaging and likely intervention. 1, 2

Why This Requires Urgent Evaluation

Ovarian Torsion Can Present Exactly As You Describe

• Torsion can occur intermittently (partial torsion) and present with waxing/waning severe pain that suddenly worsens, which matches your clinical picture 1, 2
• Normal labs do not exclude torsion—the diagnosis is clinical and imaging-based, not laboratory-based 1, 2
• Your rapidly enlarging hemorrhagic cyst significantly increases torsion risk, particularly with preserved ovaries post-hysterectomy where the ovary has increased mobility 1, 2
• Difficulty urinating suggests possible mass effect or peritoneal irritation from rupture or torsion 3

Von Willebrand Disease Creates Unique Hemorrhagic Risks

• Women with VWD have a documented increased risk of hemorrhagic ovarian cysts that can cause massive hemoperitoneum, even from normal ovulation 4, 5
• Your 15-pound weight loss and severe symptoms raise concern for ongoing intra-abdominal bleeding that may not have been adequately assessed 4
• VWD patients can develop life-threatening bleeding from ovarian pathology that would be minor in other patients 4, 5

Your Symptom Severity Indicates Inadequate Initial Workup

• Vomiting from pain, inability to sleep, cold sweats, and 10/10 pain unresponsive to opioids suggests either progression of disease or missed diagnosis 1, 2
• The fact that IV dilaudid and ketamine only temporarily controlled your pain indicates a surgical problem, not just pain management failure 4

Specific Imaging and Tests to Request

Primary Imaging Study

Request a contrast-enhanced CT scan of the abdomen and pelvis with IV contrast (not just ultrasound) 6, 7

• CT is superior to ultrasound for detecting:
  • Free fluid/hemoperitoneum from cyst rupture 6
  • Ovarian torsion (look for ovarian enlargement, twisted pedicle, lack of enhancement) 6, 7
  • Active arterial bleeding (contrast extravasation) 7

Bedside Ultrasound Assessment

Request an E-FAST (Extended Focused Assessment with Sonography for Trauma) or comprehensive pelvic ultrasound with Doppler 6, 7

• Doppler flow assessment of the ovary is critical—absent or decreased flow suggests torsion 6
• E-FAST can rapidly detect free fluid in the peritoneal cavity with 97% positive predictive value for intra-abdominal bleeding 6
• Document the current cyst size and characteristics 6

Laboratory Studies

• Complete blood count to assess for anemia from ongoing bleeding 4
• Type and screen given your VWD and potential need for surgery 4
• VWF levels and factor VIII levels (though these don't change acute management, they guide perioperative planning) 1, 4

Pain Management Options Safe for VWD

Acute Pain Control in the ER

Opioid analgesics remain your primary option since NSAIDs are contraindicated 1, 2

• IV hydromorphone (Dilaudid) or morphine for immediate severe pain 4
• Consider IV ketamine infusion (sub-anesthetic doses) for refractory pain—you responded to oral ketamine previously 4
• Acetaminophen IV (if available) can be added for multimodal analgesia, though you've found it ineffective 1

Short-Term Outpatient Management (If Discharged)

• Extended-release oxycodone or hydromorphone rather than short-acting formulations for continuous severe pain 1, 2
• Two days of oxycodone 5 mg was grossly inadequate for your pain severity—advocate for appropriate dosing and duration 1
• Consider tramadol as an adjunct, though it's weaker than what you likely need 1

Avoid Completely

• All NSAIDs (ibuprofen, naproxen, ketorolac) due to platelet dysfunction risk with VWD 1, 2
• Aspirin and aspirin-containing products 1, 2

Should You Go to a Different Hospital?

Yes, strongly consider going to a different facility, ideally a tertiary care center with:

• 24/7 gynecologic surgery availability (not just on-call) 7
• Hematology consultation available for VWD management 1, 4
• Interventional radiology for potential angiography/embolization if bleeding is identified 7
• Experience managing complex bleeding disorders in surgical patients 4

Why a Different Hospital May Be Better

• Your initial hospital discharged you with inadequate pain control and potentially incomplete evaluation given symptom progression 1
• A facility familiar with VWD can coordinate hematology and gynecology for perioperative factor replacement if surgery is needed 4
• Tertiary centers are more likely to have protocols for managing hemorrhagic complications in bleeding disorder patients 4

Critical Pitfalls to Avoid

Common Diagnostic Errors

• Don't accept reassurance based solely on "normal labs"—ovarian torsion and hemorrhagic cysts are diagnosed by imaging and clinical presentation, not bloodwork 1, 4
• Don't allow providers to dismiss your pain severity—women with VWD have documented increased risk of hemorrhagic ovarian complications that can be life-threatening 4, 5
• Insist on Doppler flow assessment of the ovary, not just standard ultrasound 6

Management Errors to Prevent

• Inadequate factor replacement before any surgical intervention—ensure hematology is involved if surgery is considered 4
• Delayed diagnosis of torsion leads to ovarian loss—time is critical if torsion is present 1
• Undertreatment of pain in VWD patients is common and unacceptable—advocate firmly for adequate analgesia 1, 2

Specific Questions to Ask in the ER

1. "Can you perform a CT scan with IV contrast to evaluate for torsion, rupture, or active bleeding?" 6, 7
2. "Can you do a Doppler ultrasound to assess blood flow to my ovary?" 6
3. "Given my Von Willebrand disease, can hematology be consulted to guide management?" 4
4. "If this is a surgical problem, what is your plan for factor replacement during surgery?" 4
5. "Can gynecology evaluate me now rather than waiting for outpatient follow-up?" 1

Do not delay—go to the ER tonight. Your symptom constellation, VWD history, and rapidly enlarging hemorrhagic cyst create a high-risk scenario that requires immediate evaluation, not outpatient follow-up. 1, 4