An acute scrotum is defined as an acute painful swelling of the scrotum or its contents, accompanied by local signs or general symptoms. Early identification and skillful management of testicular torsion is critical, as it may threaten testicular viability and future fertility if not managed expediently and appropriately. The cremasteric reflex and testicular sonography are frequently used, yet imperfect, diagnostic tools in assessing for testicular torsion. Other emergent conditions include incarcerated inguinal hernia, Fournier's gangrene, and any form of genitourinary trauma until proven otherwise. This article reviews the evaluation and management of the acute scrotum in the emergency department.