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Abstract Background Spontaneous idiopathic testicular hemorrhage is an extremely rare entity with few published reports in the literature. Case presentation We report a case of a 15-year-old boy who had been experiencing intense, left scrotal pain for the previous twelve hours. No previous history of trauma or bleeding disorders. The left testis was enlarged and tender. Left orchiectomy was performed. The entire testis was dusty and dark grossly. Microscopic sections show diffuse intratesticular bleeding with intact seminiferous tubules and spermatogenesis. Conclusions Spontaneous idiopathic testicular hemorrhage should be considered when evaluating patients with acute scrotal pain. Clinical and ultrasonographic findings and histopathologic evaluation are mandatory to diagnose it.