In the pediatric age group, color Doppler sonography appears to be as accurate as scintigraphy in evaluating causes of acute scrotal pain, provided that sensitivity for detecting low-velocity flow is adequate. Sonography has the advantage of providing anatomic information and it lacks radiation. Scintigraphy remains a reliable method of evaluating acute scrotal pain and should be used when color Doppler sensitivity for low-velocity, low-volume testicular blood flow is inadequate leading to doubt about the sonographic diagnosis. It is also advocated when examiner expertise with color Doppler sonography is limited. Regardless of which imaging study one prefers, it needs to be recognized that imaging of any type is not warranted in patients with a high clinical suspicion of torsion, because it delays immediate surgical treatment needed to prevent permanent damage.