AbstractThe acute scrotum remains a difficult clinical challenge because of numerous etiologies including inflammatory processes, testicular torsions, traumas, and tumors that can justify early surgery. Ultrasound study appears to be the imaging modality of choice to confirm the clinical assessment. We reviewed 825 scrotal scans performed with high‐resolution scanners; 283 were considered pathologic and classified as follows: 27 tumors (9.5%), 21 traumas including torsions (7.4%), 142 infectious diseases (50.1%), 99 dystrophic diseases (29.2%), and 16 miscellaneous (5.6%). Acute scrotal pain was the only symptom in 83 cases (29.3%). In this paper, we emphasize the different roles of ultrasound depending on the initial clinical presentation, which determines the clinician's questions. In the typical cases, ultrasound has a major role in the prognosis, as it allows evaluation of the severity of the lesions. On the other hand, in atypical cases, ultrasound has a decisive role in planning the management, which will be immediate surgery when sonographic findings highly suspicious for testicular torsion or acute ischemia of the testis are found. Based on our experience, we believe that ultrasound is a highly reliable modality for guiding medical or surgical treatment of an acute scrotu