Epidermoid cysts are benign simple epithelial tumors usually appearing as hypoechoic lesions with scattered echogenic reflectors on sonography. Herein, we present a 53-year-old man with an extratesticular epidermoid cyst in the right scrotum which shows confusing sonographic findings, normal-appearing echogenicity of the lesion and atrophied testis, which lead to a diagnostic dilemma. With a variety of sonographic presentations in extratesticular epidermoid cysts, magnetic resonance (MR) imaging could play a complementary role in difficult cases.