Introduction Acute scrotal pain in adult is classified as a medical emergency, necessitating accurate assessment. Common causes include inflammation, trauma and testicular torsion[1]. In cases of testicular torsion, the viability of the testis is dependent on the interval between onset of pain and surgical intervention[2]. A 90% salvage rate is possible for patients who are treated within 4-6 hours, while the salvage rate can drop to 45% with delayed interventions[3]. While clinical and physical examination are essential, B-mode and colour Doppler ultrasound are indispensable because of their moderate-high sensitivity (69-90%) and high specificity (98-100%)[4]. Ultrasound is also cost-effective, swift and non-invasive, leading to timely diagnosis and appropriate treatment plan. Colour Doppler imaging with B-mode ultrasound, allows dynamic assessment of the scrotal structure, reveals testicular perfusion status and possible extent of ischemic injury. Ultrasound strain elastography (SE) shows potential in distinguishing between pathologies and improving clinical diagnosis[3]. Learning Objectives This exhibit aims to: 1. Review the role of ultrasound in diagnosing and distinguishing various acute testicular pathologies. 2. Describe and discuss the sonographic appearances of commonly encountered pathologies utilising various ultrasound imaging techniques (Greyscale, colour Doppler and SE). 3. Evaluate the potentials, pitfalls and limitations of these techniques in diagnosing acute scrotal pain. Imaging Findings In this review, we present a spectrum of cases to demonstrate the sonographic findings of various pathologies commonly encountered in adult acute scrotal pain during the course of our daily practice. The pathologies discussed included testicular torsion, rupture, epididymitis, orchitis and epididymo-orchitis. Both testicular and extra-testicular components are assessed with B-mode and colour Doppler. SE was applied in some cases, and further correlation with other available imaging modalities and/or histopathology were also included wherever available. Insights on recognizing and strategies in overcoming the pitfalls are discussed. Conclusion The ability to identify the sonographic appearances of various scrotal pathologies allows for improving the diagnostic confidence and accuracy. This non-invasive examination of the scrotum improves patient outcomes by decreasing morbidity and avoiding unnecessary and risky surgical exploration.