Every male patient with the acute onset of pain and swelling of the scrotum requires an immediate evaluation to have the presence of testicular torsion diagnosed or excluded. Although several acute scrotal conditions can present in a similar fashion, testicular torsion is by far the most significant. Testicular torsion is a true surgical emergency because the likelihood of testicular salvage decreases as the duration of torsion increases. Other conditions that may present in a similar manner to testicular torsion include torsion of a testicular or epididymal appendage, epididymitis, epididymo-orchitis, trauma to the scrotum, hernia/hydrocele, varicocele and Henoch-Schönlein purpura. However, these conditions do not generally require urgent surgical intervention. In most patients, it should be possible to establish the correct diagnosis based on a detailed history and physical examination combined with the appropriate use of imaging studies. Herein we will describe our approach to the evaluation of children with acute scrotums.