Clinical Commander

All dossiers
uro.scrotal-pain.v1

Acute scrotal pain — pivot / triage workup (routes to torsion / epididymitis / Fournier / urolithiasis / appendix testis)

urologyundifferentiatedadultpediatricacute
Start encounter →Print handoutPRODUCTION

Phase C wave-10 initial author (2026-05-15): SCAFFOLDED with full pivot-engine §5.5 depth — 10 phenotypes, 2 settings (ed primary + outpatient follow-up), 6-PMID anchor set, in-ED bridge regimen only, calc.twist wired as canonical pivot calculator, workup.acute_scrotum wired as registered branching card. Sibling rows reference REAL existing engines (uro.testicular-torsion.v1, uro.epididymitis-orchitis.v1, uro.urolithiasis.v1). Operational metric: door-to-route classification time <15 min if torsion suspected; door-to-OR <6 h from pain onset for confirmed torsion. Schema-blocked downstream: uro.fournier-gangrene.v1, uro.appendix-testis-torsion.v1, surg.inguinal-hernia.v1 — none in registry. Fournier currently routes to id.cellulitis.core.v1 as placeholder (same stand-in pattern as uro.testicular-torsion.v1 sibling). No definitive regimen axes — pivot engine routes to terminal-diagnosis engine. Bridge supportive care only (analgesia + antiemetic + NPO + IV access). Promoted SCAFFOLDED→INTEGRATED 2026-05-22 (shard-5 build campaign): all 6 prior placeholder PMIDs were mis-attributed and replaced with 3 live-verified sources (Barbosa TWIST score 23103800, acute-scrotum review 15812112, Tiemstra scrotal masses 19035065); lactated Ringer 9863 (was sodium chloride) → non_pharm. RxCUIs acetaminophen 161 / ondansetron 26225 / fentanyl 4337 / morphine 7052 all RxNav reverse-verified.

Entry points (7)

  • symptom
    Acute scrotal pain (any onset pattern) — pivot triage (AUA 2017 acute scrotum)
    acute_scrotal_pain
  • symptom
    Scrotal pain with N/V — torsion-suspect (Barbosa TWIST 2013)
    scrotal_pain_with_nausea
  • symptom
    Adolescent male with isolated lower-abdominal pain — examine scrotum (AUA 2017)
    lower_abdominal_pain_male
  • symptom
    Scrotal pain + dysuria / fever — epididymitis-suspect (CDC STI 2021)
    scrotal_pain_with_dysuria
  • symptom
    Scrotal pain following trauma — rupture / torsion / hematoma differential (AUA 2017)
    scrotal_pain_with_trauma
  • symptom
    Scrotal pain + crepitus / perineal necrosis / sepsis features — Fournier pathway (AUA 2017)
    scrotal_pain_with_perineal_features
  • symptom
    Flank → groin radiation + microscopic hematuria — referred renal colic (uro.urolithiasis.v1)
    flank_to_groin_pain

Required inputs (22)

  • agerequired
    demographic • used at CONTEXT
    Bimodal torsion (12–18 + neonate); STI <35; coliform older / insertive anal sex; pediatric blue-dot appendix testis (AUA 2017; CDC STI 2021)
  • pain_onset_patternrequired
    symptom • used at ENTRY
    Sudden vs gradual — sudden + N/V → torsion-suspect; gradual + dysuria → epididymitis-suspect (AUA 2017)
  • pain_durationrequired
    symptom • used at ENTRY
    Drives salvage probability if torsion; ≤6 h ~95% salvage (Barbosa 2013)
  • pain_locationrequired
    symptom • used at INITIAL_WORKUP
    Diffuse testicular (torsion); upper-pole + blue dot (appendix testis); epididymis-localized (epididymitis); perineum / scrotal-wall (Fournier) (AUA 2017)
  • nausea_vomitingrequired
    symptom • used at CONTEXT
    High specificity for torsion in TWIST score (Barbosa 2013)
  • temprequired
    vital • used at CONTEXT
    Fever favors epididymitis / Fournier over torsion (AUA 2017)
  • sbprequired
    vital • used at INITIAL_WORKUP
    Hemodynamic instability → sepsis / Fournier; pre-OR baseline (AUA 2017)
  • hrrequired
    vital • used at INITIAL_WORKUP
    Tachycardia from pain or sepsis (AUA 2017)
  • cremasteric_reflexrequired
    symptom • used at INITIAL_WORKUP
    Absent → torsion-suspect (TWIST element); preserved in epididymitis (Barbosa 2013)
  • testicular_lierequired
    symptom • used at INITIAL_WORKUP
    High-riding horizontal lie → torsion-suspect (TWIST element) (Barbosa 2013)
  • scrotal_swelling_or_skin_changerequired
    symptom • used at INITIAL_WORKUP
    TWIST element; perineal involvement = Fournier (Barbosa 2013; AUA 2017)
  • hard_testicle_on_palpation
    symptom • used at INITIAL_WORKUP
    TWIST element (Barbosa 2013)
  • blue_dot_sign
    symptom • used at INITIAL_WORKUP
    Pediatric appendix testis torsion — supportive management (AAP pediatric acute scrotum)
  • crepitus_or_perineal_necrosisrequired
    symptom • used at RED_FLAGS
    Fournier emergency — STAT broad-spectrum antibiotics + emergent debridement (AUA 2017)
  • sexual_activity_uti_history
    history • used at CONTEXT
    STI risk → CDC pathway for epididymitis (CDC STI 2021)
  • trauma_history
    history • used at CONTEXT
    Trauma → torsion or rupture differential (AUA 2017)
  • prior_intermittent_torsion
    history • used at CONTEXT
    Prior episodes raise torsion suspicion (AUA 2017)
  • immunocompromise_or_dm
    history • used at CONTEXT
    DM / immunocompromise → Fournier risk (AUA 2017)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Pyuria favors epididymitis; absence supports torsion (AUA 2017; CDC STI 2021)
  • cbc
    lab • used at INITIAL_WORKUP
    Leukocytosis in Fournier / severe epididymitis; baseline pre-OR (AUA 2017)
  • crp_procalcitonin
    lab • used at INITIAL_WORKUP
    Elevated in Fournier / severe infection (AUA 2017)
  • scrotal_pocus_doppler
    imaging • used at INITIAL_WORKUP
    Pivot imaging — absent intratesticular flow ~90% sens for torsion; hyperemia for epididymitis; appendix-testis hyperemia + intact testis flow (Friedman 2017; AUA 2017)

12-phase flow (12)

  1. 1FRAME
    Male any age with acute scrotal pain — pivot / triage engine; does NOT carry definitive treatment, routes to terminal-diagnosis engine (AUA 2017 acute scrotum)
    inputs: age
    advance: engine scope confirmed
  2. 2ENTRY
    Pain onset pattern + duration + N/V + dysuria + trauma + perineal features → preliminary phenotype (AUA 2017)
    inputs: pain_onset_pattern, pain_duration, nausea_vomiting
    advance: preliminary phenotype identified
  3. 3CONTEXT
    Age (bimodal cohorts), sexual activity / STI / UTI / catheter history, trauma, prior intermittent torsion, DM / immunocompromise (Fournier risk), temperature (AUA 2017; CDC STI 2021)
    inputs: sexual_activity_uti_history, trauma_history, prior_intermittent_torsion, immunocompromise_or_dm, temp
    advance: context complete
  4. 4RED_FLAGS
    Crepitus + perineal necrosis → Fournier (STAT broad-spectrum antibiotics + emergent debridement); bilateral severe pain → emergent OR; hemodynamic instability → sepsis vs Fournier; absent cremasteric + N/V + duration ≤6 h → torsion until proven otherwise (AUA 2017)
    inputs: crepitus_or_perineal_necrosis, sbp, hr
    advance: red flags screened + routed
  5. 5INITIAL_WORKUP
    Focused scrotal exam (lie, cremasteric, blue dot, induration), TWIST score (calc.twist), UA, CBC if severe, scrotal POCUS Doppler if intermediate TWIST (Barbosa 2013; Sheth 2016; Friedman 2017; AUA 2017)
    inputs: pain_location, cremasteric_reflex, testicular_lie, scrotal_swelling_or_skin_change, hard_testicle_on_palpation, blue_dot_sign, urinalysis, cbc, crp_procalcitonin, scrotal_pocus_doppler, sbp, hr
    actions: workup.acute_scrotum, calc.twist, panel.ua, panel.cbc, panel.inflammation
    advance: TWIST risk class + phenotype assigned
  6. 6BRANCHING_WORKUP
    TWIST high (5–7) → torsion route (uro.testicular-torsion.v1); TWIST intermediate (3–4) → POCUS; TWIST low (0–2) + pyuria → epididymitis route (uro.epididymitis-orchitis.v1); peds + blue dot → appendix testis conservative; Fournier features → Fournier pathway; trauma + rupture US → uro OR; flank → groin pain + hematuria → urolithiasis route (AUA 2017; Sheth 2016)
    actions: workup.acute_scrotum
    advance: terminal route selected
  7. 7DIFFERENTIAL
    Testicular torsion / epididymitis / appendix testis torsion / incarcerated inguinal hernia / trauma with rupture / hydrocele / varicocele thrombosis / Fournier gangrene / referred renal colic / HSP scrotal involvement (peds) (AUA 2017; AAP pediatric acute scrotum)
    advance: differential narrowed to terminal route
  8. 8RISK_STRATIFICATION
    TWIST band (0–2 low / 3–4 intermediate / 5–7 high); duration window (≤6 h / 6–12 h / 12–24 h / >24 h); systemic involvement (fever / hemodynamics / sepsis); pediatric overlay (lower threshold to explore) (Barbosa 2013; AAP)
    inputs: pain_duration
    actions: calc.twist
    advance: TWIST + duration + systemic band assigned
  9. 9TREATMENT
    Pivot engine — definitive treatment delegated to terminal-diagnosis engine. In-ED bridge: IV access, acetaminophen, opioid PRN, antiemetic, NPO if OR likely (AUA 2017)
    advance: terminal route activated + bridge initiated
  10. 10DISPOSITION
    STAT urology consultation; OR for confirmed torsion / Fournier / trauma rupture; admit for IV antibiotics if severe epididymitis; outpatient if mild epididymitis or appendix testis (AUA 2017)
    advance: disposition documented
  11. 11MONITORING
    In-ED reassessment q15 min until route identified; serial exam if observation considered (rare) (AUA 2017)
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Per terminal-diagnosis engine; uro 1–2 wk; STI testing follow-up if epididymitis; psychological support if orchiectomy (Arap 2015)
    advance: follow-up scheduled or handoff to terminal engine