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uro.testicular-torsion.v1

Testicular torsion (time-critical scrotal emergency, <6 h salvage window)

urologyacuteadultpediatricacuteinpatient
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Phase B deepening (2026-05-14): time-window phenotypes (≤6 h / 6–12 h / 12–24 h / >24 h) + intermittent torsion + bell-clapper + neonatal + POCUS-absent-flow + manual-detorsion-attempt phenotypes encoded as severity_triggers — pivot from sibling rows because per-time-window dossiers do not exist (same engine, different management branch). 5 setting playbooks span the full journey: home (caregiver action plan + EMS routing) → ed (TWIST + POCUS + STAT urology + manual detorsion bridge) → icu (rare, only for Fournier overlay / septic shock) → inpatient (post-op recovery + fertility counsel) → outpatient (1–2 wk / 6 wk / 3–6 mo semen analysis / 12 mo final outcome). calc.twist IS in clinical-tools-registry (line 468) and is surfaced as a first-class calculators[] row with band-mapped guideline_basis (0–2 low / 3–4 intermediate / 5–7 high). Pathway: TWIST score → if high (5–7) go straight to OR (do not wait for POCUS); manual detorsion as bridge (open like a book — outward rotation typical, ~2/3 torsion is medial); bilateral orchiopexy in same operation (bell-clapper is bilateral). Schema-blocked downstream — `uro.epididymitis.core.v1` and `uro.fournier-gangrene.core.v1` engines do not yet exist; current sibling row uses `id.cellulitis.core.v1` as stand-in pivot. Appendix-testis torsion encoded as self-referential sibling pending Phase C dedicated engine. 2026-05-22 citation remediation — all 8 prior PMIDs were live-checked on PubMed and found mis-attributed to unrelated articles; replaced with 4 PubMed-verified testicular-torsion anchors (TWIST derivation 23103800, POCUS meta 35523539, Doppler-US accuracy 23617512, time-dependent salvage 28527721). RxCUIs reverse-verified on RxNav; Lactated Ringer set non_pharm (multi-ingredient).

Entry points (5)

  • symptom
    Sudden severe unilateral scrotal pain (AUA 2017)
    sudden_severe_scrotal_pain
  • symptom
    Scrotal pain with nausea / vomiting (high specificity; Barbosa 2013 TWIST)
    scrotal_pain_with_nausea
  • symptom
    Adolescent male with isolated lower-abdominal pain — examine scrotum (AUA 2017)
    lower_abdominal_pain_male
  • history
    Prior episodes of intermittent torsion / detorsion (AUA 2017)
    prior_intermittent_torsion
  • history
    Bell-clapper deformity, undescended testis, prior pexy on contralateral side (EAU paediatric urology)
    bell_clapper_or_undescended_testis

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Bimodal — neonates (extravaginal) and adolescents 12–18 y (intravaginal); bimodal incidence informs index of suspicion (AUA 2017)
  • pain_onset_durationrequired
    symptom • used at ENTRY
    Time from onset directly drives salvage probability (≤6 h ~95%, 6–12 h ~70%, 12–24 h ~20%, >24 h <10%) and OR urgency (Barbosa 2013)
  • nausea_vomitingrequired
    symptom • used at CONTEXT
    High specificity feature in TWIST score (Barbosa 2013)
  • high_riding_testisrequired
    symptom • used at CONTEXT
    TWIST + clinical exam — high-riding testis with horizontal lie (Barbosa 2013)
  • absent_cremasteric_reflexrequired
    symptom • used at CONTEXT
    High sensitivity (loss highly suggestive of torsion); TWIST component (Barbosa 2013)
  • scrotal_swelling_or_skin_change
    symptom • used at CONTEXT
    TWIST scoring; later finding (Barbosa 2013)
  • hard_testicle_on_palpation
    symptom • used at CONTEXT
    TWIST component — hard induration of testis (Barbosa 2013)
  • scrotal_pocus_doppler
    imaging • used at INITIAL_WORKUP
    Decreased / absent intratesticular arterial flow + whirlpool sign of cord; high-resolution POCUS ~90% sensitive but operator-dependent — do NOT delay surgery if high clinical suspicion (Friedman 2017; AUA 2017)
  • urinalysis
    lab • used at INITIAL_WORKUP
    Pyuria suggests epididymitis; absence supports torsion (AUA 2017)
  • sbprequired
    vital • used at INITIAL_WORKUP
    Hemodynamic baseline pre-OR (AUA 2017)
  • hrrequired
    vital • used at INITIAL_WORKUP
    Pain-related tachycardia baseline (AUA 2017)
  • temprequired
    vital • used at CONTEXT
    Fever atypical — points more toward epididymitis or abscess; high fever + crepitus → Fournier (AUA 2017)
  • sexual_activity_uti_history
    history • used at CONTEXT
    STI / UTI history points toward epididymitis (CDC STI 2021)
  • trauma_history
    history • used at CONTEXT
    Trauma can precipitate torsion (intermittent or with frank rupture); rule out intratesticular hematoma / rupture (AUA 2017)

12-phase flow (12)

  1. 1FRAME
    Time-critical surgical emergency — door-to-OR clock starts at pain onset; preserve viable testis (AUA 2017)
    inputs: age, pain_onset_duration
    advance: torsion suspected
  2. 2ENTRY
    Capture trigger: sudden severe scrotal pain ± lower abdominal, N/V, high-riding testis, absent cremasteric reflex (Barbosa 2013)
    inputs: pain_onset_duration, nausea_vomiting
    advance: high-suspicion presentation documented
  3. 3CONTEXT
    Age, prior intermittent torsion, bell-clapper anatomy, undescended testis, sexual / UTI / trauma history (AUA 2017; EAU paediatric urology)
    inputs: nausea_vomiting, high_riding_testis, absent_cremasteric_reflex, sexual_activity_uti_history, trauma_history, temp
    advance: context complete
  4. 4RED_FLAGS
    Pain >6 h with classic features → OR now even if Doppler equivocal; never wait for Doppler if exam strongly suggests torsion (AUA 2017)
    inputs: pain_onset_duration
    advance: OR pathway initiated for high suspicion
  5. 5INITIAL_WORKUP
    TWIST score (testicular swelling, hard testicle, absent cremasteric, nausea/vomiting, high-riding); high-resolution scrotal POCUS if score intermediate; UA to gauge epididymitis (Barbosa 2013; Sheth 2016; Friedman 2017)
    inputs: absent_cremasteric_reflex, high_riding_testis, urinalysis
    actions: workup.acute_scrotum, calc.twist
    advance: TWIST risk class assigned and surgical decision made
  6. 6BRANCHING_WORKUP
    TWIST high (5–7) → straight to OR; intermediate (3–4) → POCUS; low (0–2) + supportive UA → empiric epididymitis treatment with close follow-up; trauma → also rule out testicular rupture (heterogeneous parenchyma, contour disruption) (Sheth 2016)
    actions: workup.acute_scrotum
    advance: pathway selected
  7. 7DIFFERENTIAL
    Testicular torsion vs epididymitis / orchitis vs torsion of testicular appendage (blue-dot sign) vs incarcerated inguinal hernia vs scrotal trauma / rupture vs Henoch-Schönlein purpura vs idiopathic scrotal edema vs Fournier gangrene (AUA 2017)
    advance: differential narrowed or surgical exploration committed
  8. 8RISK_STRATIFICATION
    Time from onset → salvage estimate (≤6 h ~95%, 6–12 h ~70%, 12–24 h ~20%, >24 h <10%); clinical TWIST score; pediatric vs adult workflow (Barbosa 2013)
    inputs: pain_onset_duration
    actions: calc.twist
    advance: salvage class documented
  9. 9TREATMENT
    Immediate scrotal exploration + manual detorsion as bridge ("open like a book" — outward/lateral rotation typically; ~2/3 torsion is medial so external rotation untwists); intra-op assessment of viability, orchiopexy of viable testis + contralateral prophylactic orchiopexy; orchiectomy if non-viable; pre-op IV opioid + antiemetic + IV access (AUA 2017; Cochrane bridge)
    inputs: pain_onset_duration
    advance: OR completed
  10. 10DISPOSITION
    OR within minutes of high-suspicion clinical decision; admission overnight; same-day discharge possible if uncomplicated orchiopexy and supportive home environment (AUA 2017)
    advance: disposition documented
  11. 11MONITORING
    Post-op pain, scrotal swelling, return precautions, incision care; 1–2 wk outpatient urology; counsel on contralateral risk and pexy outcome (AUA 2017)
    advance: discharge criteria met
  12. 12FOLLOWUP
    Outpatient urology 1–2 wk + 6 wk; semen analysis 3–6 mo (post-orchiectomy or unilateral pexy + family planning); psychological support if orchiectomy; fertility / hormone discussion; activity restriction 4–6 wk; contralateral fixation at later date if not done at index operation (long-term fertility data per Arap et al)
    advance: follow-up scheduled