Abstract Reconstruction of major scrotal defects represent a great challenge for surgeons, Although a lot of therapeutic methods have been established for the reconstruction of these defects each technique has its own advantages and disadvantages, The pudendal thigh flap is an axial and sensate fasciocutaneuos flap based on the terminal branches of the superficial perineal artery which is a continuation of the internal pudendal artery (below the urogenital diaphragm). The data on the testicular function after reconstruction of cover for the testes have been rarely reported. In this study, followed-up of patients with pudendal thigh flap was done regarding aesthetic, functional outcome, and testicular function. Aim: The aim of this study was to show the versatility and usefulness of posteriorly based pudendal thigh flap for scrotal reconstruction and to evaluate its effect on testicular function. Patient and Methods: nineteen flaps in 13 patients with major scrotal defects were subjected to reconstruction using posteriorly based pudendal thigh flap. The cause of scrotal skin loss was Fournier gangrene in nine cases, trauma in three cases, and animal bite in one case. Sex patients underwent bilateral and 7 patient unilateral flap reconstructions. Results: All 19 flaps survived completely with good color matching, the donor site was closed directly, and the scar was hidden in the inguinal crease. One patient had wound dehiscence in the donor site and required a secondary procedure for healing. Testicular function regarding spermatogenesis and hormonal functions showed non-significant changes 6months and one year after flap coverage. Conclusion: posteriorly based pudendal thigh flap is a good option for reconstruction of major scrotal defects. This flap gives a wide coverage with excellent aesthetic appearance of the scrotum, without any significant effect on testicular function.