Objectives: To provide a rational approach to the diagnosis and management of blunt scrotal trauma to aid clinicians in the selection of patients for surgical exploration. Methods: We performed a retrospective evaluation of the medical records of 44 patients from two metropolitan tertiary referral hospitals. A total of 29 patients were recruited from July 1, 1993 to June 30, 2003 at one institution and an additional 15 patients from February 1, 1991 to January 31, 1999 at the second. Scrotal ultrasound scans were retrieved and reviewed by a uroradiologist unaware of the treatment regimen and outcome. Results: The presence of both testicular swelling and tenderness suggested more significant testicular injury; however, testicular rupture was present in the absence of tenderness. Three patients with operatively confirmed testicular rupture had only swelling on clinical examination. Five patients with intratesticular hematoma were successfully treated conservatively with interval ultrasound scans recommended to assess for resolution. All patients with operatively confirmed testicular rupture had a combination of the following ultrasound features: the presence of hematocele, disruption of the tunica albuginea, and/or extrusion of the seminiferous tubules. Conclusions: Patients presenting after blunt scrotal trauma with clinical hematocele should progress directly to exploration. The remainder should undergo scrotal ultrasonography. Those with large hematoceles or suspected rupture on ultrasonography should also proceed to exploration. Those without hematocele, a clearly distinct tunica albuginea, and a lack of fracture planes within the testes are a subgroup that can be successfully treated conservatively.