Scrotal masses are caused by a variety of disorders, ranging from benign conditions to those requiring emergent surgical intervention. Painful scrotal masses require urgent evaluation. Characteristics that suggest testicular torsion include rapid symptom onset, nausea and vomiting, high position of the testicle, and abnormal cremasteric reflex. Doppler ultrasonography or surgical exploration is required to confirm the diagnosis. Surgical repair must occur within six hours of symptom onset to reliably salvage the testicle. Epididymitis/orchitis have a slower onset and are associated with a C-reactive protein level greater than 24 mg per L (228.6 nmol per L) and increased blood flow on ultrasonography. Acute onset of pain with near normal physical examination and ultrasound findings is consistent with torsion of the testicular appendage. Testicular malignancies cause pain in 15% of cases. If ultrasonography shows an intratesticular mass, timely urology referral is indicated. Inguinal hernias are palpated separate to the testicle and can cause pain. Emergent surgery is indicated for a strangulated hernia. Hydrocele, varicocele, and scrotal skin lesions may be managed in nonurgent settings. A biopsy should be performed to rule out cancer in patients with scrotal skin lesions that are erosive, vascular, hyperkeratotic, or nonhealing, or that change color or have irregular borders.