Purpose or Case Report: Background: Acute scrotum in children encompasses a spectrum of causes, from benign self-limiting conditions to life-threatening emergencies requiring urgent surgery. Among them, torsion of a hernia or hydrocele sac is exceptionally rare and scarcely described in the literature. Case Presentation and Literature Review: An 8-year-old boy presented with acute right-sided scrotal pain, swelling, and erythema. There was no fever, abdominal pain, or vomiting. A communicating hydrocele had been diagnosed months earlier. Examination revealed a swollen, tender right hemiscrotum with a non-palpable testis. Laboratory findings were unremarkable. Ultrasonography demonstrated a well-defined, right-sided cystic mass with thick echogenic walls, low-level internal echoes, and septations (48 × 28 × 24 mm) without internal vascularity on Doppler. A surrounding communicating hydrocele was visualized, and the right testis appeared compressed but with preserved perfusion. Surgical exploration revealed a patent processus vaginalis and a large hydrocele sac containing clear fluid. Within it, a second bluish, necrotic sac connected to the hydrocele neck showed multiple twists. The necrotic sac was excised, the hydrocele drained, and high ligation of the processus vaginalis was performed. The postoperative course was uneventful, and the patient was discharged on day three. Histopathology confirmed a necrotic membranous sac with vascular congestion and advanced hemorrhagic infarction. A literature review identified only 15 pediatric cases, none previously reported in the radiological literature. Six involved a cystic hernia sac that likely prolapsed or intussuscepted into a pre-existing hydrocele before torsion and infarction, as in our case; seven described isolated hernia sac torsion without an associated hydrocele, and two reported torsion of a hydrocele sac. Patients were aged 2–10 years, with 10 cases on the right side, consistent with the higher incidence of right-sided inguinal hernias. All underwent emergency surgical excision of the twisted sac and closure of the peritoneal-vaginal communication. Conclusion: Torsion of a hernia or hydrocele sac, though exceedingly rare, should be recognized as a potential cause of acute scrotum in children. Awareness of its imaging features enables timely diagnosis and guides urgent surgical intervention, improving patient outcomes
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