Regardless of age, any presentation of an acute scrotum requires prompt triage and immediate evaluation. The potential for significant reduction in morbidity and mortality exists if timely diagnosis and treatment are provided. Often overlooked, an early scrotal examination in the emergency department may produce the most accurate information into the underlying pathologic process, be it systemic or localized to the scrotum. Although the immediately lethal conditions presenting as acute scrotal pain should be considered, the combined incidence and morbidity associated with testicular torsion make its exclusion paramount in acute scrotal presentations. Similarly, a painless scrotal mass must be assumed to be a testicular neoplasm until proven otherwise, with appropriate work-up and rapid urologic follow-up assured.