Get documents about "ACR Appropriateness Criteria Recurrent Lower Urinary Tract Urinary Tract Infection
Document Sample
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;
475-554.
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
women.
• 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
cystoscopy.
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
studies.
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-
45.
* 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-
794.
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
pyelonephritis.
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;
172(6):1491-1494.
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
calculi.
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;
64(759):221-224.
* 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
diverticulum.
• 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
techniques.
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
(83%).
• 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
radiography
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
fistulae.
* 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
http://www.acr.org/SecondaryMainMenuC associated with the use of contrast media.
ategories/quality_safety/contrast_manual.a
spx.
* 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
