ACR Appropriateness Criteria Recurrent Lower Urinary Tract Urinary Tract Infection

					ACR Appropriateness Criteria®
                                                                 Recurrent Lower Urinary Tract Infections in Women
                                                                               EVIDENCE TABLE

                                                                  Patients/                  Study Objective                                                                          Strength of
                   Reference                       Study Type                                                                                     Study Results
                                                                   Events                   (Purpose of Study)                                                                         Evidence
1.   Foxman B, Barlow R, D'Arcy H, Gillespie          15        2,000 women   Analysis of a random digit dialing survey of       Overall, an estimated 11.3 million women in the           2
     B, Sobel JD. Urinary tract infection: self-                              women to estimate the annual incidence,            United States had at least one presumed UTI
     reported incidence and associated costs.                                 cumulative probability of presumed UTI by          treated with antibiotics in 1995. Authors
     Ann Epidemiol 2000; 10(8):509-515.                                       age, and the social costs.                         estimate the annual cost of UTI cases with
                                                                                                                                 prescriptions to be $1.6 billion in 1995. If the
                                                                                                                                 costs occurring after 1995 are discounted at 5%
                                                                                                                                 annually, the total cost over 20 years has a
                                                                                                                                 present value of $25.5 billion. If a vaccine were
                                                                                                                                 developed that would prevent either initial or
                                                                                                                                 recurrent UTI the net benefits to society would
                                                                                                                                 be substantial, even at a developmental cost of
                                                                                                                                 one billion dollars.
2.   Wagenlehner FM, Weidner W, Naber KG.             12           N/A        Review recent developments in epidemiology,        Remarkable increase of antibiotic resistance is          4
     An update on uncomplicated urinary tract                                 pathogenesis, cause, diagnosis, treatment and      also in uncomplicated UTI. Therefore, careful
     infections in women. Curr Opin Urol                                      prevention of uncomplicated UTI and recurrent      use of antibiotic substances in uncomplicated
     2009; 19(4):368-374.                                                     UTI in women.                                      UTI is increasingly important.
3.   Stamey TA. Pathogenesis and treatment of         15           N/A        Evaluate the etiologies, clinical presentations,   Guidelines for diagnosis and therapy of UTI.             4
     urinary tract infections. Baltimore, MD:                                 and therapy of UTI.
     Williams & Wilkins. 1980:43-47; 179-199;
4.   Sheffield JS, Cunningham FG. Urinary             12           N/A        Review UTI in women.                               Pregnancy is a common cause of obstructive               4
     tract infection in women. Obstet Gynecol                                                                                    uropathy, and severe renal infections are
     2005; 106(5 Pt 1):1085-1092.                                                                                                relatively common. Because they usually arise
                                                                                                                                 from preexisting covert bacteriuria, experts
                                                                                                                                 recommend screening and eradication of these
                                                                                                                                 silent infections as a routine prenatal practice.
5.   Haylen BT, Lee J, Husselbee S, Law M,            10        1,140 women   Prospective urogynecological study assessing       • The overall prevalence of recurrent UTI was            2
     Zhou J. Recurrent urinary tract infections                               women and the prevalence of UTI.                      19%.
     in women with symptoms of pelvic floor                                                                                      • Significant positive associations of recurrent
     dysfunction. Int Urogynecol J Pelvic Floor                                                                                     UTI were:
     Dysfunct 2009; 20(7):837-842.                                                                                                  1) Nulliparity with a 3.7 x (up to 50 years)
                                                                                                                                          increase over the prevalence for parous
                                                                                                                                          women and 1.8 x (over 50 years),
                                                                                                                                    2) Women with an immediate postvoid
                                                                                                                                          residual over 30 ml, which is significant
                                                                                                                                          in women over 50 years.
                                                                                                                                 • The early age decline (18-45 years) in the
                                                                                                                                    prevalence of recurrent UTI might be related
                                                                                                                                    to increasing parity. The later increase (over
                                                                                                                                    55 years) was probably due to the increasing
                                                                                                                                    postvoid residual effect superimposed on the
                                                                                                                                    nulliparity effect.

* See Last Page for Key                                                               Review 2011                                                                                             Lazarus
                                                                                                                                                                                               Page 1
ACR Appropriateness Criteria®
                                                                   Recurrent Lower Urinary Tract Infections in Women
                                                                                 EVIDENCE TABLE

                                                                     Patients/                    Study Objective                                                                    Strength of
                   Reference                         Study Type                                                                                   Study Results
                                                                      Events                    (Purpose of Study)                                                                    Evidence
6.   Raz R, Gennesin Y, Wasser J, et al.                 9          202 total     A case-control study to evaluate and compare   • 3 urologic factors-namely, incontinence                2
     Recurrent urinary tract infections in                           patients     factors associated with recurrent UTI in          (41% of case patients vs 9.0% of control
     postmenopausal women. Clin Infect Dis                          149 with      postmenopausal women.                             patients; P<.001), presence of a cystocele
     2000; 30(1):152-156.                                           history of                                                      (19% vs 0%; P<.001), and postvoiding
                                                                  recurrent UTI                                                     residual urine (28% vs 2.0%; P=.00008),
                                                                   53 controls                                                      were all strongly associated with recurrent
                                                                     with no                                                        UTI.
                                                                    history of                                                   • Multivariate analysis showed that urinary
                                                                       UTI                                                          incontinence (OR, 5.79; 95% CI, 2.05-16.42;
                                                                                                                                    P=.0009), a history of UTI before menopause
                                                                                                                                    (OR, 4.85; 95% CI, 1.7-13.84; P=. 003), and
                                                                                                                                    nonsecretor status (OR, 2.9; 95% CI, 1.28-
                                                                                                                                    6.25; P=.005) were most strongly associated
                                                                                                                                    with recurrent UTI in postmenopausal
                                                                                                                                 • Prospective studies are needed to confirm
                                                                                                                                    these observations and to develop approaches
                                                                                                                                    for prevention.
7.   Fihn SD. Clinical practice. Acute                  12            N/A         Article presents a case vignette of a woman    Women who have frequent recurrences, such as            3
     uncomplicated urinary tract infection in                                     with UTI, review strategies and evidence of    the patient in the vignette, are advised to avoid
     women. N Engl J Med 2003; 349(3):259-                                        UTI and gives clinical recommendations.        exposure to vaginal spermicides and should be
     266.                                                                                                                        offered prophylaxis or methods of self-
                                                                                                                                 treatment. Imaging studies should be reserved
                                                                                                                                 for women with complicated infections.
8.   Browne RF, Zwirewich C, Torreggiani                12            N/A         Review imaging of UTI in adults.               CT is now accepted as a sensitive modality for          4
     WC. Imaging of urinary tract infection in                                                                                   diagnosis and follow-up of complicated renal
     the adult Eur Radiol 2004; 14 Suppl                                                                                         tract infection. Contrast-enhanced CT allows
     3:E168-183.                                                                                                                 different phases of excretion to be studied.
                                                                                                                                 Nuclear medicine has a limited role in the
                                                                                                                                 evaluation of UTI in adults. MRI has a limited
                                                                                                                                 but increasing role.
9.   Schaeffer AJ. Infections of the urinary            15            N/A         Book chapter.                                  N/A                                                    N/A
     tract. In: Walsh JP, et al., eds. Campbell's
     urology. 6th ed. Philadelphia, Pa: WB
     Saunders; 1992:731-806.
10. Stamm WE. Cystitis and urethritis. In:              15            N/A         Book chapter.                                  N/A                                                    N/A
     Schrier RW, Gottschalk CW, eds. Diseases
     of the kidney. 5th ed. Boston, Mass: Little,
     Brown; 1993:1007-1027.
11. De Lange EE, Jones B. Unnecessary                   13        201 patients    Analysis of the benefit of IVU in young        Other risk indications are necessary to justify         2
     intravenous urography in young women                                         women (ages 15-30 years) with recurrent UTI.   the cost, gonadal irradiation and workload of
     with recurrent urinary tract infections. Clin                                                                               IVU.
     Radiol 1983; 34(5):551-553.
* See Last Page for Key                                                                   Review 2011                                                                                        Lazarus
                                                                                                                                                                                              Page 2
ACR Appropriateness Criteria®
                                                                 Recurrent Lower Urinary Tract Infections in Women
                                                                               EVIDENCE TABLE

                                                                 Patients/                     Study Objective                                                                          Strength of
                  Reference                        Study Type                                                                                        Study Results
                                                                  Events                     (Purpose of Study)                                                                          Evidence
12. Engel G, Schaeffer AJ, Grayhack JT,                9        153 patients    To evaluate the role of excretory urography        Excretory urography limited to those patients             2
    Wendel EF. The role of excretory                                            and cystoscopy in managing recurrent UTI in        who have risk factors other than recurrent UTI.
    urography and cystoscopy in the evaluation                                  healthy women seen consecutively with              On the other hand, cystoscopy under local
    and management of women with recurrent                                      recurrent UTIs.                                    anesthesia has essentially no risks and
    urinary tract infection. J Urol 1980;                                                                                          occasionally will yield information helpful in
    123(2):190-191.                                                                                                                future management.
13. Fair WR, McClennan BL, Jost RG. Are               10        164 excretory   To evaluate the yield of excretory urograms in     Routine use of the excretory urograms in                 2
    excretory urograms necessary in evaluating                    urograms      identifying significant urinary tract              women with recurrent UTI has little
    women with urinary tract infection? J Urol                                  abnormalities; women with recurrent UTI.           justification and a negative cost/benefit.
    1979; 121(3):313-315.
14. Fairchild TN, Shuman W, Berger RE.                13         78 patients    To determine the value of roentgenographic         Radiographic evaluation is beneficial in select          3
    Radiographic studies for women with                                         examination in the management of women             patients (ie, those with additional risk factors).
    recurrent urinary tract infections. J Urol                                  with recurrent UTI.
    1982; 128(2):344-345.
15. Mermuys K, De Geeter F, Bacher K, et al.           9         50 patients    Comparison of diagnostic performance of            Digital tomosynthesis performed better than              2
    Digital tomosynthesis in the detection of                                   digital tomosynthesis and digital radiography      digital radiography for detection of renal calculi
    urolithiasis: Diagnostic performance and                                    for detection of renal calculi with NCCT used      but not for detection of ureteral calculi. Mean
    dosimetry      compared     with     digital                                as the gold standard.                              effective radiation dose was 0.5 mSv for digital
    radiography with MDCT as the reference                                                                                         radiography, 0.85 mSv for tomosynthesis, 2.5
    standard. AJR 2010; 195(1):161-167.                                                                                            mSv for low-dose MDCT, and 12.6 mSv for
                                                                                                                                   high-dose MDCT.
16. Pollack HM, Banner MP, Martinez LO,               13         19 patients    Review of the causes of bladder wall               A correct diagnosis is possible by combining             3
    Hodson CJ. Diagnostic considerations in                                     calcifications with emphasis on the clinical and   history, clinical examination, lab and
    urinary bladder wall calcification. AJR                                     radiographic features.                             radiograph; Cystoscopy with biopsy is almost
    1981; 136(4):791-797.                                                                                                          necessary.
17. Silverman SG, Leyendecker JR, Amis ES,            12            N/A         To review the current role of urography in the     CT urography is the current heir apparent to             4
    Jr. What is the current role of CT                                          postintravenous urography era and provide          IVU, but because of its potential advantages,
    urography and MR urography in the                                           expository summaries of CT urography and           MRU may one day be the urographic test of
    evaluation of the urinary tract? Radiology                                  MRU, while addressing the rationale,               choice particularly in young patients and
    2009; 250(2):309-323.                                                       techniques, effectiveness, indications, and        patients who need repeated examinations.
                                                                                vulnerabilities of these newer modalities that
                                                                                have now become primary in imaging the
                                                                                urinary tract.

* See Last Page for Key                                                                 Review 2011                                                                                             Lazarus
                                                                                                                                                                                                 Page 3
ACR Appropriateness Criteria®
                                                                  Recurrent Lower Urinary Tract Infections in Women
                                                                                EVIDENCE TABLE

                                                                  Patients/                      Study Objective                                                                      Strength of
                   Reference                        Study Type                                                                                     Study Results
                                                                   Events                      (Purpose of Study)                                                                      Evidence
18. Lawrentschuk N, Ooi J, Pang A, Naidu KS,           10        118 patients   Retrospective study to determine if women         NPV of imaging was 99% and significant                   2
    Bolton DM. Cystoscopy in women with                                         with recurrent UTI warrant cystoscopy to          (P<0.01). Women with no risk factors for UTI
    recurrent urinary tract infection. Int J Urol                               exclude an abnormality of the lower urinary       had a NPV of 93% for normal cystoscopy
    2006; 13(4):350-353.                                                        tract. Also, to correlate imaging and risk        (P>0.05). PPV was low for imaging and risk
                                                                                factors with cystoscopic findings to determine    factors in predicting cystoscopy findings. In the
                                                                                their predictive value in finding pathology.      study, 8% of women had significant
                                                                                                                                  abnormalities detected during cystoscopy with
                                                                                                                                  most over 50 years. Women without risk factors
                                                                                                                                  for recurrent UTI and with normal imaging
                                                                                                                                  could have a cystoscopy omitted. Younger
                                                                                                                                  women are less likely to have pathology and
                                                                                                                                  this must be factored into decisions to perform
19. Caoili EM, Cohan RH, Korobkin M, et al.             9        65 patients    Comparative study on findings from CT             MDCT urography depicted many clinically                 2
    Urinary   tract  abnormalities:   initial                                   urography, urinalysis, cystoscopy and/or          diagnosed urinary tract abnormalities, including
    experience with multi-detector row CT                                       ureteroscopy, and/or surgery to determine the     15/16 uroepithelial malignancies, five
    urography. Radiology 2002; 222(2):353-                                      usefulness of MDCT urography in detecting         congenital anomalies, five urinary tract calculi,
    360.                                                                        urinary tract abnormalities.                      and 18 calyceal and/or papillary, 30 renal pelvic
                                                                                                                                  and/or ureteral, and 25 bladder abnormalities.
                                                                                                                                  All abnormalities were detected on transverse
                                                                                                                                  images. MDCT urography is a useful method
                                                                                                                                  for detecting urinary tract abnormalities.
20. Chow LC, Sommer FG. Multidetector CT               12           N/A         Analysis on the use of CT urography in            CT urography is an evolving technique and is            4
    urography with abdominal compression                                        evaluating patients with hematuria.               subject to controversy. Although in theory it
    and three-dimensional reconstruction. AJR                                                                                     seems an ideal method, its ability to detect
    2001; 177(4):849-855.                                                                                                         disease has not yet been proven by prospective
21. Dillman JR, Caoili EM, Cohan RH. Multi-            12           N/A         Review indications, specific techniques, image    While the concept of CT urography has been              4
    detector CT urography: a one-stop renal                                     reconstruction/reformatting, detection of         utilized for nearly a decade, there is still no
    and urinary tract imaging modality. Abdom                                   pathology, and pitfalls related to CT             universally accepted technique.
    Imaging 2007; 32(4):519-529.                                                urography.
22. Baumgarten DA, Baumgartner BR.                     12           N/A         Review imaging and radiologic management          CT is the study of choice to define the extent of       4
    Imaging and radiologic management of                                        of upper UTI.                                     disease and to help direct percutaneous
    upper urinary tract infections. Urol Clin                                                                                     intervention.
    North Am 1997; 24(3):545-569.
23. Mindelzun RE, Jeffrey RB. Unenhanced               12           N/A         Analysis of literature data to assess cost-       Unenhanced CT provides clinically relevant              4
    helical CT for evaluating acute abdominal                                   effective imaging triage of patients with acute   information in most patients at a reasonable
    pain: a little more cost, a lot more                                        abdominal pain.                                   cost.
    information. Radiology 1997; 205(1):43-

* See Last Page for Key                                                                 Review 2011                                                                                           Lazarus
                                                                                                                                                                                               Page 4
ACR Appropriateness Criteria®
                                                                Recurrent Lower Urinary Tract Infections in Women
                                                                              EVIDENCE TABLE

                                                                Patients/                     Study Objective                                                                     Strength of
                  Reference                       Study Type                                                                                    Study Results
                                                                 Events                     (Purpose of Study)                                                                     Evidence
24. Smith RC, Rosenfield AT, Choe KA, et al.          9        20 patients    To compare NCCT and IVU in the evaluation        Two techniques are equally effective in                 3
    Acute flank pain: comparison of non-                                      of patients with acute flank pain.               identification of obstruction; CT superior for
    contrast-enhanced CT and intravenous                                                                                       identification of ureteric stones.
    urography. Radiology 1995; 194(3):789-
25. Smith RC, Verga M, McCarthy S,                   10        210 patients   To determine the value of unenhanced CT in       Sensitivity of 97%, specificity of 96%, and             2
    Rosenfield AT. Diagnosis of acute flank                                   the diagnosis of acute flank pain.               accuracy of 97% for diagnosis of ureteral stone
    pain: value of unenhanced helical CT. AJR                                                                                  disease. Unenhanced CT is an accurate
    1996; 166(1):97-101.                                                                                                       technique.
26. Stunell H, Buckley O, Feeney J,                  12           N/A         Review on the role of CT and MRI techniques      Imaging may not only aid in making the                 4
    Geoghegan T, Browne RF, Torreggiani                                       in the imaging of acute pyelonephritis and its   diagnosis of acute pyelonephritis, but may help
    WC. Imaging of acute pyelonephritis in the                                complications.                                   identify complications such as abscess
    adult. Eur Radiol 2007; 17(7):1820-1828.                                                                                   formation.
27. Craig WD, Wagner BJ, Travis MD.                  12           N/A         Review imaging of pyelonephritis.                CT, when performed before, immediately after,          4
    Pyelonephritis:      radiologic-pathologic                                                                                 and at delayed intervals from contrast material
    review. Radiographics 2008; 28(1):255-                                                                                     injection, is the preferred modality for
    277; quiz 327-258.                                                                                                         evaluating acute bacterial pyelonephritis. CT is
                                                                                                                               also preferred over conventional radiography
                                                                                                                               and US for assessing emphysematous
28. Sourtzis S, Thibeau JF, Damry N, Raslan           9        53 patients    Prospective study to compare unenhanced          CT better than urography in identifying ureteral        2
    A, Vandendris M, Bellemans M.                                             helical CT with excretory urography in the       stones.
    Radiologic investigation of renal colic:                                  patients with renal colic.
    unenhanced helical CT compared with
    excretory     urography.     AJR     1999;
29. Jin DH, Lamberton GR, Broome DR, et al.           9        57 patients    To determine, using calculi placed in cadaver    Decreasing tube charge from 100 mAs to 30              2
    Effect of reduced radiation CT protocols on                               kidneys, the effect of reduced radiation dose    mAs did not significantly alter the detection of
    the detection of renal calculi. Radiology                                 (100, 60, and 30 mAs) on the sensitivity and     renal calculi.
    2010; 255(1):100-107.                                                     specificity of MDCT for detection of renal
30. McNicholas MM, Griffin JF, Cantwell DF.           9        94 patients    Prospective study to compare the value of US     US of the pelvis and renal tract combined with         2
    Ultrasound of the pelvis and renal tract                                  and KUB with IVU in young women with             KUB should be the radiological exam of choice.
    combined with a plain film of abdomen in                                  recurrent UTI.
    young women with urinary tract infection:
    can it replace intravenous urography? A
    prospective study. Br J Radiol 1991;

* See Last Page for Key                                                               Review 2011                                                                                          Lazarus
                                                                                                                                                                                            Page 5
ACR Appropriateness Criteria®
                                                              Recurrent Lower Urinary Tract Infections in Women
                                                                            EVIDENCE TABLE

                                                               Patients/                     Study Objective                                                                      Strength of
                  Reference                     Study Type                                                                                     Study Results
                                                                Events                     (Purpose of Study)                                                                      Evidence
31. Majd M, Nussbaum Blask AR, Markle               9         35 piglets     To compare the sensitivity and specificity of    • Histopathologic examination revealed                   3
    BM, et al. Acute pyelonephritis:                         (70 kidneys)    technetium-99m dimercaptosuccinic acid              pyelonephritis in 102 zones in 38 kidneys.
    comparison of diagnosis with 99mTc-                                      SPECT, spiral CT, MRI, and power Doppler         • Sensitivity and specificity for detecting
    DMSA, SPECT, spiral CT, MR imaging,                                      US for the detection and localization of acute      pyelonephritis in the kidneys were 92.1% and
    and power Doppler US in an experimental                                  pyelonephritis by using histopathologic             93.8% for SPECT, 89.5% and 87.5% for
    pig model. Radiology 2001; 218(1):101-                                   findings as the standard of reference.              MRI, 86.8% and 87.5% for CT, and 74.3%
    108.                                                                                                                         and 56.7% for US.
                                                                                                                              • Sensitivity and specificity for detecting
                                                                                                                                 pyelonephritis in the zones were 94.1% and
                                                                                                                                 95.4% for SPECT, 91.2% and 92.6% for
                                                                                                                                 MRI, 88.2% and 93.5% for CT, and 56.6%
                                                                                                                                 and 81.4% for US.
                                                                                                                              • The pairwise comparison of these modalities
                                                                                                                                 showed no statistically significant difference
                                                                                                                                 among them except for US.
                                                                                                                              • Technetium-99m dimercaptosuccinic acid
                                                                                                                                 SPECT, spiral CT, and MRI appear to be
                                                                                                                                 equally sensitive and reliable for the
                                                                                                                                 detection of acute pyelonephritis; power
                                                                                                                                 Doppler US is significantly less accurate.
32. Martina MC, Campanino PP, Caraffo F, et        10              442       Retrospective study to evaluate the role and     MRI showed signal abnormalities suggestive of           2
    al. Dynamic magnetic resonance imaging                    consecutive    clinical impact of dynamic MRI in the            acute pyelonephritis in 125/244 (51.2%)
    in acute pyelonephritis. Radiol Med 2010;                  renal MRI     diagnosis and follow-up of acute                 patients with native kidneys. Abscesses were
    115(2):287-300.                                          examinations    pyelonephritis.                                  present in 40/123 (32.5%) positive cases.
                                                                  (279                                                        During follow-up, complete normalization of
                                                               diagnostic                                                     MRI signs in 86/103 patients; 17/103 (16.5%)
                                                                and 163                                                       cases evolved into fibrosis and scarring. In
                                                               follow-up)                                                     15/35 (42.8%) patients with transplanted
                                                             performed in                                                     kidney, MRI was positive for acute
                                                              285 patients                                                    pyelonephritis. Renal MRI is an effective tool
                                                                                                                              for the diagnosis and follow-up of acute
                                                                                                                              pyelonephritis both in patients not at risk and
                                                                                                                              those at higher risk, such as those with a
                                                                                                                              transplanted kidney.

* See Last Page for Key                                                              Review 2011                                                                                          Lazarus
                                                                                                                                                                                           Page 6
ACR Appropriateness Criteria®
                                                             Recurrent Lower Urinary Tract Infections in Women
                                                                           EVIDENCE TABLE

                                                             Patients/                   Study Objective                                                                    Strength of
                  Reference                     Study Type                                                                               Study Results
                                                              Events                   (Purpose of Study)                                                                    Evidence
33. Boyadzhyan L, Raman SS, Raz S. Role of         12          N/A       To review the role of static and dynamic MRI   The recent development of fast MRI sequences             4
    static and dynamic MR imaging in surgical                            in surgical pelvic floor dysfunction.          allows noninvasive, radiation-free, rapid, high-
    pelvic floor dysfunction. Radiographics                                                                             resolution evaluation of the entire pelvis in one
    2008; 28(4):949-967.                                                                                                examination. The H line, M line, organ prolapse
                                                                                                                        classification system, which is applied to
                                                                                                                        dynamic MRI, allows consistent standardization
                                                                                                                        and grading of various forms of pelvic floor
                                                                                                                        dysfunction. In addition, the H line, M line,
                                                                                                                        organ prolapse system clearly defines and
                                                                                                                        differentiates between the two main
                                                                                                                        components of pelvic floor dysfunction: pelvic
                                                                                                                        floor relaxation and pelvic organ prolapse. In
                                                                                                                        addition to serving as an objective diagnostic
                                                                                                                        tool in patients with surgical pelvic floor
                                                                                                                        dysfunction, MRI has tremendous potential to
                                                                                                                        be used as a research tool in trying to
                                                                                                                        understand the pathophysiology of these
                                                                                                                        complex disorders.
34. Woodfield CA, Krishnamoorthy S,                12          N/A       To review the relevant anatomy and             Disorders of the pelvic floor are a                     4
    Hampton BS, Brody JM. Imaging pelvic                                 sonographic, fluoroscopic, and MRI options     heterogeneous and complex group of problems.
    floor     disorders:    trend   toward                               for evaluating patients with pelvic floor      Imaging can help elucidate the presence and
    comprehensive      MRI.     AJR  2010;                               disorders.                                     extent of pelvic floor abnormalities. MRI is
    194(6):1640-1649.                                                                                                   particularly well suited for global pelvic floor
                                                                                                                        assessment including pelvic organ prolapse,
                                                                                                                        defecatory function, and pelvic floor support
                                                                                                                        structure integrity.

* See Last Page for Key                                                          Review 2011                                                                                        Lazarus
                                                                                                                                                                                     Page 7
ACR Appropriateness Criteria®
                                                               Recurrent Lower Urinary Tract Infections in Women
                                                                             EVIDENCE TABLE

                                                                Patients/                     Study Objective                                                                        Strength of
                  Reference                      Study Type                                                                                      Study Results
                                                                 Events                     (Purpose of Study)                                                                        Evidence
35. Foster RT, Amundsen CL, Webster GD.             13         27 women       To report the value of MRI in the evaluation of   • The mean time from onset of symptoms to                 3
    The utility of magnetic resonance imaging                 with urethral   urethral diverticulum in women.                      diagnosis of a urethral diverticulum was 47
    for diagnosis and surgical planning before                diverticulum                                                         months.
    transvaginal periurethral diverticulectomy                                                                                  • 7 (26%) women had a history of one or more
    in women. Int Urogynecol J Pelvic Floor                                                                                        prior diverticulectomies, and 8 (30%) had
    Dysfunct 2007; 18(3):315-319.                                                                                                  prior incontinence or other urethral surgery.
                                                                                                                                • 21 (78%) had undergone a preoperative MRI,
                                                                                                                                   which detected the diverticulum in all cases.
                                                                                                                                   In 3 women, multiple other prior imaging
                                                                                                                                   studies had failed to identify the diverticulum
                                                                                                                                   despite clinical suspicion of its presence.
                                                                                                                                • MRI revealed an unsuspected
                                                                                                                                   intradiverticular carcinoma in one patient.
                                                                                                                                • 26 women were treated with periurethral
                                                                                                                                   diverticulectomy, and one patient was treated
                                                                                                                                   with cystourethrectomy.
                                                                                                                                • Average follow-up was 9 (range 1-60)
                                                                                                                                   months. No patients had significant
                                                                                                                                   intraoperative complications. One patient
                                                                                                                                   was diagnosed (by MRI) with a recurrent
                                                                                                                                • The use of preoperative MRI altered the
                                                                                                                                   management in 15% of patients.
                                                                                                                                   Furthermore, this study cohort had a long
                                                                                                                                   duration of complex symptoms with one-
                                                                                                                                   third having had prior urethral surgery.
                                                                                                                                • The use of MRI allows for accurate diagnosis
                                                                                                                                   and improved surgical planning.
36. Healy JC, Phillips RR, Reznek RH,               10        15 patients     To determine the accuracy of MRI in revealing     Vaginal fistulas were seen in 10 patients. All           3
    Crawford RA, Armstrong P, Shepherd JH.                                    complex vaginal fistulas.                         fistulas were confirmed surgically. Of the 5
    The MR appearance of vaginal fistulas.                                                                                      patients with no fistulas revealed on MRI,
    AJR 1996; 167(6):1487-1489.                                                                                                 examination under anesthesia also revealed no
                                                                                                                                fistulas in four. However, in the fifth patient,
                                                                                                                                examination under anesthesia revealed an
                                                                                                                                epithelialized track, which was not seen on
                                                                                                                                MRI. MRI was accurate in revealing and
                                                                                                                                delineating the extent of vaginal fistulas in
                                                                                                                                patients with clinical symptoms of such fistulas.

* See Last Page for Key                                                               Review 2011                                                                                            Lazarus
                                                                                                                                                                                              Page 8
ACR Appropriateness Criteria®
                                                                 Recurrent Lower Urinary Tract Infections in Women
                                                                               EVIDENCE TABLE

                                                                 Patients/                      Study Objective                                                                          Strength of
                  Reference                       Study Type                                                                                        Study Results
                                                                  Events                      (Purpose of Study)                                                                          Evidence
37. Outwater E, Schiebler ML. Pelvic fistulas:       12            N/A          Pictorial essay illustrating findings on MRI in   • Most enterocutaneous fistulas arise as a                  4
    findings on MR images. AJR 1993;                                            patients who had pelvic fistulas.                    complication of gastrointestinal surgery or
    160(2):327-330.                                                                                                                  inflammatory bowel disease.
                                                                                                                                  • They are frequently associated with intra-
                                                                                                                                     abdominal on pelvic abscesses.
                                                                                                                                     Enterocutaneous fistulas appear on T2-
                                                                                                                                     weighted images as fluid-filled tracks,
                                                                                                                                     surrounded by fibrosis and granulation tissue
                                                                                                                                     that has lower signal intensity.
                                                                                                                                  • Fast spin-echo images yield relatively higher
                                                                                                                                     signal intensity for adipose tissue, therefore it
                                                                                                                                     is helpful to suppress the subcutaneous fat
                                                                                                                                     signal with chemical-shift-selective
38. Shokeir AA, El-Diasty T, Eassa W, et al.          9         149 patients    Prospective study to compare the role of          • The definitive cause of ureteral obstruction             1
    Diagnosis of ureteral obstruction in                         (110 had       NCCT, MRU, and combined KUB and US in                was calculous in 146 and noncalculous in
    patients with compromised renal function:                     bilateral     the diagnosis of the cause of ureteral               113 renal units.
    the role of noninvasive imaging modalities.                 obstruction     obstruction in patients with compromised renal    • The site of stone impaction was identified by
    J Urol 2004; 171(6 Pt 1):2303-2306.                         and 39 had      function. The gold standard included                 NCCT in all 146 renal units (100%
                                                               obstruction of   retrograde or antegrade ureterogram,                 sensitivity), by MRU in 101 (69.2%
                                                                 a solitary     ureteroscopy and/or open surgery.                    sensitivity), and by combined KUB and US
                                                                  kidney)                                                            in 115 (78.7% sensitivity).
                                                                 259 renal                                                        • Ureteral strictures were identified by NCCT
                                                                    units                                                            in 18/65 cases (28%) and by MRU in 54/65
                                                                                                                                  • Overall of the 113 kidneys with noncalculous
                                                                                                                                     obstruction the cause could be identified by
                                                                                                                                     MRU in 101 (89% sensitivity), by NCCT in
                                                                                                                                     45 (40% sensitivity), and by combined KUB
                                                                                                                                     and US in only 20 (18% sensitivity) with a
                                                                                                                                     difference of significant value in favor of
                                                                                                                                     MRU (P<0.001).
                                                                                                                                  • In patients with renal impairment due to
                                                                                                                                     ureteral obstruction NCCT has superior
                                                                                                                                     diagnostic accuracy for detecting calculous
                                                                                                                                     causes of obstruction but MRU is superior
                                                                                                                                     for identifying noncalculous lesions.
39. Amar AD, Das S. Vesicoureteral reflux in         13         12 patients     To describe management of women with              Ureteral reimplantation after excision of the              3
    women with primary bladder diverticulum.                                    chronic UTI, vesicoureteral reflux and vesical    bladder diverticulum and repair of the bladder
    J Urol 1985; 134(1):33-35.                                                  diverticulum.                                     wall was successful in eradicating reflux in 5
                                                                                                                                  patients. Bladder diverticula may perpetuate
                                                                                                                                  reflux and their detection is important in
                                                                                                                                  planning treatment.
* See Last Page for Key                                                                 Review 2011                                                                                              Lazarus
                                                                                                                                                                                                  Page 9
ACR Appropriateness Criteria®
                                                               Recurrent Lower Urinary Tract Infections in Women
                                                                             EVIDENCE TABLE

                                                                Patients/                    Study Objective                                                                       Strength of
                  Reference                      Study Type                                                                                     Study Results
                                                                 Events                    (Purpose of Study)                                                                       Evidence
40. Chang YL, Lin AT, Chen KK. Presentation          9         14 patients    Retrospective study. A report on the authors’    • Recurrent UTI, urinary incontinence,                   3
    of female urethral diverticulum is usually                                experience on the diversity of presenting           palpable suburethral mass, vaginal
    not typical. Urol Int 2008; 80(1):41-45.                                  symptoms and signs of female urethral               tenderness, and dysuria are the five major
                                                                              diverticula.                                        presenting symptoms and signs.
                                                                                                                               • The diagnostic rate of voiding
                                                                                                                                  cystourethrography during video-
                                                                                                                                  urodynamics, double-balloon urethrography
                                                                                                                                  and MRI were 10/10 (100%), 6/6 (100%) and
                                                                                                                                  10/11 (90.9%) respectively.
                                                                                                                               • The presenting symptoms and signs of
                                                                                                                                  female urethral diverticula are often diverse
                                                                                                                                  and easily overlooked. High suspicion of this
                                                                                                                                  disorder, detailed history-taking and physical
                                                                                                                                  examination are essential for detecting
                                                                                                                                  urethral diverticulum in females.
41. Chou CP, Huang JS, Wu MT, et al. CT             10            14 CT       To demonstrate CT voiding urethrography and      The full urethral structure was clearly shown by        3
    voiding    urethrography    and   virtual                    voiding      CT virtual urethroscopy. CT voiding              CT voiding urethrography and virtual
    urethroscopy: preliminary study with 16-                  urethrograph    urethrography examinations were                  urethroscopy in all patients. The results of CT
    MDCT. AJR 2005; 184(6):1882-1888.                          y exams on     prospectively performed.                         voiding urethrography and conventional
                                                                 13 men                                                        methods correlated closely with the urethral
                                                                                                                               diseases being imaged.
42. Chou CP, Levenson RB, Elsayes KM, et al.        12            N/A         Review the anatomic and pathologic features      Modern imaging techniques, including US,                4
    Imaging of female urethral diverticulum:                                  of female urethral diverticulum. Also, discuss   MRI, voiding CT urethrography, and virtual
    an     update.   Radiographics     2008;                                  and illustrate various diagnostic methods for    urethroscopy, can help precisely identify a
    28(7):1917-1930.                                                          evaluating female urethral diverticulum.         female urethral diverticulum, locate its orifice,
                                                                                                                               and differentiate it from other paraurethral
                                                                                                                               pathologic conditions.
43. Zoeller G, May C, Vosshenrich R, et al.          9         19 patients    To determine the extent of radiation dose        Radiation dose of digital radiography was               3
    Digital radiography in urologic imaging:                  conventional    reduction possible in urethrocystography with    reduced by about 90% compared to
    radiation     dose     reduction      on                   radiologic     digital radiography.                             conventional screen film.
    urethrocystography. Urol Radiol 1992;                     system in 10
    14(1):56-58.                                               and digital
                                                                   in 9
44. Goldman SM, Fishman EK, Gatewood                10              20        To examine the use of CT in the diagnosis of     The CT findings included intravesical air               3
    OM, Jones B, Siegelman SS. CT in the                      enterovesical   enterovesical fistulae.                          (90%), passage of orally or rectally
    diagnosis of enterovesical fistulae. AJR                     fistulae                                                      administered contrast medium into the bladder
    1985; 144(6):1229-1233.                                                                                                    (20%), focal bladder-wall thickening (90%),
                                                                                                                               thickening of adjacent bowel wall (85%), and
                                                                                                                               an extraluminal mass that often contained air
                                                                                                                               (75%). CT proved to be an important new
                                                                                                                               method in the diagnosis of enterovesical
* See Last Page for Key                                                               Review 2011                                                                                          Lazarus
                                                                                                                                                                                           Page 10
ACR Appropriateness Criteria®
                                                              Recurrent Lower Urinary Tract Infections in Women
                                                                            EVIDENCE TABLE

                                                               Patients/                    Study Objective                                                                       Strength of
                  Reference                      Study Type                                                                                     Study Results
                                                                Events                    (Purpose of Study)                                                                       Evidence
45. Kavanagh D, Neary P, Dodd JD, Sheahan            9        30 patients   To describe diagnosis and treatment of             The commonest investigations (n, % positive)            3
    KM, O'Donoghue D, Hyland JM.                                            enterovesical fistulae in a retrospective study.   included CT (15, 80%), cystoscopy (16,
    Diagnosis and treatment of enterovesical                                CT, cystoscopy, endoscopy and barium enema         87.5%), endoscopy (11, 54.5%) and barium
    fistulae. Colorectal Dis 2005; 7(3):286-                                were examined.                                     enema (8, 50%). There were 20 inflammatory
    291.                                                                                                                       and 10 neoplastic etiologies. Classical urinary
                                                                                                                               symptoms were only evident in 50% of patients
                                                                                                                               with confirmed fistulae. Authors recommend
                                                                                                                               CT scanning as the optimum imaging modality
                                                                                                                               before surgical intervention. Surgical treatment
                                                                                                                               in a specialized unit remains the most effective
                                                                                                                               treatment of enterovesical fistulae.
46. Yu NC, Raman SS, Patel M, Barbaric Z.           12           N/A        Review imaging of genitourinary tract fistula.     Imaging plays a crucial role in delineating the        4
    Fistulas of the genitourinary tract: a                                                                                     anatomy and extent of the fistulous tract. In
    radiologic review. Radiographics 2004;                                                                                     addition to direct endoscopic techniques and
    24(5):1331-1352.                                                                                                           traditional contrast-enhanced studies under
                                                                                                                               fluoroscopy, cross-sectional modalities such as
                                                                                                                               CT, MRI, and US have gained increasing
                                                                                                                               support. The volumetric and multiplanar
                                                                                                                               capabilities of MRI and modern CT systems, in
                                                                                                                               particular, may maximize diagnostic yield.
47. American College of Radiology. Manual           15           N/A        Guidance document on contrast media to assist      N/A                                                    3
    on Contrast Media. Available at:                                        radiologists in recognizing and managing risks                                   associated with the use of contrast media.

* See Last Page for Key                                                             Review 2011                                                                                           Lazarus
                                                                                                                                                                                          Page 11
ACR Appropriateness Criteria®

                             Evidence Table Key                                                                           Abbreviations Key
Study Type Key                                                                          CI = Confidence interval
Numbers 1-7 are for studies of therapies while numbers 8-15 are used to describe        CT = Computed tomography
studies of diagnostics.
    1. Randomized Controlled Trial — Treatment                                          IVU = Intravenous urography
    2. Controlled Trial                                                                 KUB = Abdominal radiography
    3. Observation Study
              a. Cohort                                                                 MDCT = Multidetector computed tomography
              b. Cross-sectional                                                        MRI = Magnetic resonance imaging
              c. Case-control
    4. Clinical Series                                                                  MRU = Magnetic resonance urography
    5. Case reviews                                                                     NCCT = Noncontrast computed tomography
    6. Anecdotes
    7. Reviews                                                                          NPV = Negative predictive value
    8.    Randomized Controlled Trial — Diagnostic                                      OR = Odds ratio
    9.    Comparative Assessment                                                        PPV = Positive predictive value
    10.   Clinical Assessment
    11.   Quantitative Review                                                           SPECT = Single-photon emission tomography
    12.   Qualitative Review
                                                                                        US = Ultrasound
    13.   Descriptive Study
    14.   Case Report                                                                   UTI = Urinary tract infection
    15.   Other (Described in text)

Strength of Evidence Key
•   Category 1 - The conclusions of the study are valid and strongly supported by
    study design, analysis and results.
•   Category 2 - The conclusions of the study are likely valid, but study design does
    not permit certainty.
•   Category 3 - The conclusions of the study may be valid but the evidence
    supporting the conclusions is inconclusive or equivocal.
•   Category 4 - The conclusions of the study may not be valid because the evidence
    may not be reliable given the study design or analysis.

ACR Appropriateness Criteria®                                                                                                                 Evidence Table Key