Imaging of acute-onset scrotal swelling with or without pain is performed emergently to establish a diagnosis and to differentiate between patients who need immediate surgical exploration and those who do not. Rapid diagnosis and initiation of treatment are vital for testicular salvage in cases of testicular rupture and ischemia, as testicular viability is directly related to the duration of ischemia. Ultrasound is the established first-line imaging modality for acute scrotal disease. When combined with clinical history and physical examination, ultrasound results can be used to diagnose most scrotal disorders. For equivocal cases that do not require immediate surgical intervention, magnetic resonance imaging (MRI) can be used to help further characterize scrotal pathology. Ultrasound imaging in patients who present within a few hours after severe torsion and complete detorsion will demonstrate hypoechoic enlargement of the epididymis and testis and a straight spermatic cord. Reperfusion after early ischemia can induce a reactive hyperemia on color Doppler imaging, which is not sonographically distinguishable from the hyperemia seen with acute epididymo-orchitis. Ultrasound is a valuable diagnostic technique for identifying scrotal and testicular traumatic injuries that require surgical intervention. POCUS can be used as a rapid, bedside imaging adjunct in the emergency setting when more precise delineation of tissue viability is needed to enable organ-sparing treatment. The main ultrasound findings for testicular rupture include a heterogeneous testicle, contour abnormality, and disruption of the tunica albuginea. Mixed echogenicity of the testicular parenchyma reflects hemorrhage and necrosis. Disruption of the normal testicular contour indicates parenchyma extrusion. Color Doppler imaging demonstrates focal or diffuse loss of vascularity, which usually requires surgical debridement