Much has been written regarding the topic of the acute scrotum, and it continues to be a focus of research and subject of debate. An embarrassing subject to discuss with patients, and often underemphasized by caretakers, the male with acute scrotal, groin, or lower abdominal pain requires prompt, accurate diagnosis and management. Although a broad scope of etiologies manifest as an acute scrotum, testicular torsion, testicular and epididymal appendage torsion and epididymitis account for the majority of presentations. We will attempt to examine the specific epidemiological, anatomic, microbiologic, pathophysiologic, and management considerations for each of the aforementioned conditions, while also discussing more rare, life-threatening presentations of the acute scrotum. Painless scrotal masses will also be discussed.