A 52-year-old male patient had complaints of right flank pain and scrotal tenderness for two days and was diagnosed with epididymitis. Antibiotics were given for his epididymitis. The flank pain and scrotal tenderness improved, but abdominal distension and paralytic ileus developed over the next two days. Under the impression of peritonitis, appendectomy was done for perforated appendicitis during laparotomy. Urinary symptoms may occur in patients with acute appendicitis. To our knowledge, scrotal tenderness is rarely the initial presentation of acute appendicitis. This rare clinical presentation and its possible mechanisms are discussed. The possibility of an acute appendicitis should also be considered in patients with right scrotal tenderness.