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uro.scrotal-pain.v1PRODUCTION
uro.scrotal-pain.v1

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

urologyundifferentiatedadultpediatric
Hard-required inputs
0 / 13
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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
1
Actions
0
Advance rule
Set
Advance when

engine scope confirmed

Patient inputs (22)

Bimodal torsion (12–18 + neonate); STI <35; coliform older / insertive anal sex; pediatric blue-dot appendix testis (AUA 2017; CDC STI 2021)

High specificity for torsion in TWIST score (Barbosa 2013)

Fever favors epididymitis / Fournier over torsion (AUA 2017)

Sudden vs gradual — sudden + N/V → torsion-suspect; gradual + dysuria → epididymitis-suspect (AUA 2017)

Drives salvage probability if torsion; ≤6 h ~95% salvage (Barbosa 2013)

Diffuse testicular (torsion); upper-pole + blue dot (appendix testis); epididymis-localized (epididymitis); perineum / scrotal-wall (Fournier) (AUA 2017)

Hemodynamic instability → sepsis / Fournier; pre-OR baseline (AUA 2017)

Tachycardia from pain or sepsis (AUA 2017)

Absent → torsion-suspect (TWIST element); preserved in epididymitis (Barbosa 2013)

High-riding horizontal lie → torsion-suspect (TWIST element) (Barbosa 2013)

TWIST element; perineal involvement = Fournier (Barbosa 2013; AUA 2017)

Pyuria favors epididymitis; absence supports torsion (AUA 2017; CDC STI 2021)

Fournier emergency — STAT broad-spectrum antibiotics + emergent debridement (AUA 2017)

STI risk → CDC pathway for epididymitis (CDC STI 2021)

Trauma → torsion or rupture differential (AUA 2017)

Prior episodes raise torsion suspicion (AUA 2017)

DM / immunocompromise → Fournier risk (AUA 2017)

TWIST element (Barbosa 2013)

Pediatric appendix testis torsion — supportive management (AAP pediatric acute scrotum)

Leukocytosis in Fournier / severe epididymitis; baseline pre-OR (AUA 2017)

Elevated in Fournier / severe infection (AUA 2017)

Pivot imaging — absent intratesticular flow ~90% sens for torsion; hyperemia for epididymitis; appendix-testis hyperemia + intact testis flow (Friedman 2017; AUA 2017)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningtwist_high_torsion_route
    TWIST 5–7 OR pain ≤6 h + classic features (sudden, N/V, absent cremasteric, high-riding) → torsion route (Barbosa 2013; AUA 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningfournier_features
    Crepitus + perineal necrosis + sepsis features → Fournier pathway (STAT broad-spectrum antibiotics + emergent surgical debridement + ICU likely) (AUA 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretwist_intermediate_pocus
    TWIST 3–4 → high-resolution scrotal POCUS Doppler; if absent intratesticular flow → torsion route (Friedman 2017; AUA 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretrauma_rupture
    Trauma + heterogeneous parenchyma / contour disruption on POCUS → uro OR for testicular rupture (AUA 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereincarcerated_inguinal_hernia
    Tender groin mass + scrotal extension + bowel symptoms → general surgery STAT (AUA 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateepididymitis_route
    Gradual onset + dysuria + pyuria on UA → epididymitis route (CDC STI 2021; AUA 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatereferred_renal_colic
    Flank → groin radiation + microscopic hematuria → referred renal colic; route to urolithiasis (AUA 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepeds_hsp_scrotal
    Pediatric vasculitic palpable purpuric rash + scrotal edema + arthralgia + abdominal pain → Henoch-Schönlein purpura scrotal involvement (AAP pediatric acute scrotum)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildappendix_testis_peds
    Pre-pubertal boy + upper-pole tenderness + blue dot sign + intact testicular flow → appendix testis (conservative) (AUA 2017; AAP pediatric acute scrotum)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildvaricocele_thrombosis
    Chronic varicocele patient with new acute scrotal pain → varicocele thrombosis (rare); uro outpatient (AUA 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

INITIAL_WORKUPrequiredDrives risk stratification
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Recommended regimen

Acute scrotal pain — in-ED bridge supportive care while routing to terminal engine (AUA 2017)
axis: scrotal_pain_bridge_supportive
Selected axis "Acute scrotal pain — in-ED bridge supportive care while routing to terminal engine (AUA 2017)" by default fallback (first axis)
  • acetaminophen
    first line
    analgesic
    15 mg/kg PO/IV (max 1 g/dose adult) • PO/IV • q6h, max 4 g/day adult
    Multimodal opioid-sparing analgesia (AUA 2017)
    rxcui 161
  • morphine
    add on
    opioid
    0.1 mg/kg IV (typical 4–10 mg adult) • IV • q3–4h PRN
    triggers: severe_acute_pain
    Severe acute pain (AUA 2017)
    rxcui 7052
  • fentanyl
    add on
    opioid
    1 µg/kg IV (typical 25–100 µg adult) • IV • q5–15 min PRN
    triggers: short_acting_titration_preferred
    Short-acting opioid for titration (AUA 2017)
    rxcui 4337
  • ondansetron
    first line
    serotonin_5HT3_antagonist
    4 mg IV (peds 0.15 mg/kg, max 4 mg) • IV • q8h PRN
    Symptom control for N/V (AUA 2017)
    rxcui 26225
  • Lactated Ringer solution
    add on
    IV_crystalloid
    500–1000 mL bolus • IV • continuous
    triggers: NPO_for_likely_OR
    Pre-OR resuscitation if route → OR (AUA 2017). non_pharm: multi-component crystalloid without a single RxNorm ingredient code.

outpatient playbook — drug actions (1)

  1. 1. acetaminophen + ibuprofen
    Acetaminophen 650 mg q6h PRN + ibuprofen 400 mg q6h PRN • PO • PRN
    trigger: Residual pain in mild epididymitis or appendix testis (AUA 2017)
    Multimodal opioid-sparing

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute scrotal pain (any onset pattern) — pivot triage (AUA 2017 acute scrotum); Scrotal pain with N/V — torsion-suspect (Barbosa TWIST 2013); Adolescent male with isolated lower-abdominal pain — examine scrotum (AUA 2017).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute scrotal pain — pivot / triage workup (routes to torsion / epididymitis / Fournier / urolithiasis / appendix testis)** (uro.scrotal-pain.v1).
Phenotype framing: 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)
Scope: Male any age with acute scrotal pain — pivot / triage engine; does NOT carry definitive treatment, routes to terminal-diagnosis engine (AUA 2017 acute scrotum)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute scrotal pain — in-ED bridge supportive care while routing to terminal engine (AUA 2017)**.
1. acetaminophen 15 mg/kg PO/IV (max 1 g/dose adult) PO/IV q6h, max 4 g/day adult (analgesic, first line) — Multimodal opioid-sparing analgesia (AUA 2017)
2. morphine 0.1 mg/kg IV (typical 4–10 mg adult) IV q3–4h PRN (opioid, add on) — Severe acute pain (AUA 2017)
3. fentanyl 1 µg/kg IV (typical 25–100 µg adult) IV q5–15 min PRN (opioid, add on) — Short-acting opioid for titration (AUA 2017)
4. ondansetron 4 mg IV (peds 0.15 mg/kg, max 4 mg) IV q8h PRN (serotonin_5HT3_antagonist, first line) — Symptom control for N/V (AUA 2017)
5. Lactated Ringer solution 500–1000 mL bolus IV continuous (IV_crystalloid, add on) — Pre-OR resuscitation if route → OR (AUA 2017). non_pharm: multi-component crystalloid without a single RxNorm ingredient code.

Setting playbook (outpatient) — Follow-up after rule-out — 24–48 h re-eval if mild epididymitis or appendix testis discharged; uro 1–2 wk; STI testing follow-up per CDC (CDC STI 2021; AUA 2017)
6. acetaminophen + ibuprofen Acetaminophen 650 mg q6h PRN + ibuprofen 400 mg q6h PRN PO PRN — Residual pain in mild epididymitis or appendix testis (AUA 2017) (Multimodal opioid-sparing)

Non-pharmacologic actions:
- Scrotal support (AUA 2017)
- Activity restriction (AUA 2017)
- Return precautions — STAT ED if new severe pain, fever, hemodynamic instability (AUA 2017)

AVOID / contraindication checks:
- NSAIDs_avoid_in_renal_impairment (AUA 2017)
- Opioid_dosing_lower_in_pediatric (AUA 2017)
- Do_not_delay_route_assignment_for_workup (AUA 2017)

Monitoring

Regimen monitoring:
- pain re evaluation q15min until route (AUA 2017)
- vitals q15min until route (AUA 2017)
- continuous SpO2 (AUA 2017)

Setting (outpatient) monitoring:
- 24–48 h re-eval if mild epididymitis or appendix testis (AUA 2017)
- 1–2 wk uro follow-up (AUA 2017)

Follow-up plan: Per terminal-diagnosis engine; uro 1–2 wk; STI testing follow-up if epididymitis; psychological support if orchiectomy (Arap 2015)
- Close-out criterion: follow-up scheduled or handoff to terminal engine

Monitoring phase: In-ED reassessment q15 min until route identified; serial exam if observation considered (rare) (AUA 2017)

Disposition

Current setting: outpatient — Follow-up after rule-out — 24–48 h re-eval if mild epididymitis or appendix testis discharged; uro 1–2 wk; STI testing follow-up per CDC (CDC STI 2021; AUA 2017)

Disposition criteria:
- Resolution at 1–2 wk → discharge from urgent follow-up; routine annual (AUA 2017)

Escalation triggers (move to higher acuity):
- New severe scrotal pain → STAT ED (AUA 2017)
- Fever or systemic features → STAT ED (AUA 2017)
- Persistent symptoms beyond expected → uro re-evaluation (AUA 2017)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] TWIST 5–7 OR pain ≤6 h + classic features (sudden, N/V, absent cremasteric, high-riding) → torsion route (Barbosa 2013; AUA 2017)
- [LIFE_THREATENING] Crepitus + perineal necrosis + sepsis features → Fournier pathway (STAT broad-spectrum antibiotics + emergent surgical debridement + ICU likely) (AUA 2017)
- [SEVERE] TWIST 3–4 → high-resolution scrotal POCUS Doppler; if absent intratesticular flow → torsion route (Friedman 2017; AUA 2017)

Citations

- Testicular torsion is a time-critical surgical emergency (salvage falls sharply after ~6 h). Barbosa TWIST clinical score (J Urol 2013 PMID 23103800) for risk stratification; acute-scrotum etiology/management (Indian J Pediatr 2005 PMID 15812112); evaluation of scrotal masses (Am Fam Physician 2008 PMID 19035065). Epididymitis antibiotic therapy follows CDC STI Treatment Guidelines 2021 (cited by name); routes to uro.epididymitis-orchitis.v1. [PMID:23103800](https://pubmed.ncbi.nlm.nih.gov/23103800/)
- Cited evidence (PMID 15812112) [PMID:15812112](https://pubmed.ncbi.nlm.nih.gov/15812112/)
- Cited evidence (PMID 19035065) [PMID:19035065](https://pubmed.ncbi.nlm.nih.gov/19035065/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Testicular torsion is a time-critical surgical emergency (salvage falls sharply after ~6 h). Barbosa TWIST clinical score (J Urol 2013 PMID 23103800) for risk stratification; acute-scrotum etiology/management (Indian J Pediatr 2005 PMID 15812112); evaluation of scrotal masses (Am Fam Physician 2008 PMID 19035065). Epididymitis antibiotic therapy follows CDC STI Treatment Guidelines 2021 (cited by name); routes to uro.epididymitis-orchitis.v1. — PMID:23103800
  • Cited evidence (PMID 15812112) — PMID:15812112
  • Cited evidence (PMID 19035065) — PMID:19035065