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Appropriateness Criteria

Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy cystocolpoproctography Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 1 1 1 0 2 4 5
References Study Quality
11 (10397095) 3
23 (24506228) 1
MR defecography Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 1 1 1 5 5
References Study Quality
27 (26867902) 3
31 (23541093) 3
30 (11997560) 2
33 (20544342) 4
15 (19188799) 3
28 (21427302) 3
41 (11425977) 1
39 (17043740) 3
42 (18193147) 3
37 (17954653) 4
43 (22068322) 4
26 (30241870) 3
32 (26880893) 3
34 (29944912) 3
35 (28386692) 4
36 (11496081) 4
38 (29409787) 2
40 (23220507) 3
29 (31494706) 3
US pelvis transperineal May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 1 0 0 1 3 3 4 1 1
References Study Quality
51 (18409183) 2
50 (20350640) 4
52 (19438878) 2
47 (26663519) 2
48 (27619683) 3
49 (28134704) Good
53 (18256847) 3
MRI pelvis dynamic maneuvers without defecation May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 1 1 8 3 0 1 0
References Study Quality
27 (26867902) 3
44 (9377520) 2
30 (11997560) 2
15 (19188799) 3
28 (21427302) 3
41 (11425977) 1
39 (17043740) 3
42 (18193147) 3
37 (17954653) 4
43 (22068322) 4
26 (30241870) 3
38 (29409787) 2
40 (23220507) 3
45 (22531955) 2
29 (31494706) 3
US pelvis transabdominal Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 4 1 0 0 1 1 0 0
US pelvis transrectal Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 3 5 3 1 1 0 1 0 0
US pelvis transvaginal Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 7 2 0 1 0 0 0 0
Fluoroscopy voiding cystourethrography Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 3 4 4 2 0 1 0 0 0
References Study Quality
14 (11445475) 2
24 (28188759) 4
25 (31307659) 3
MRI pelvis without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 4 7 2 0 0 1 0 0 0
References Study Quality
41 (11425977) 1
39 (17043740) 3
42 (18193147) 3
37 (17954653) 4
43 (22068322) 4
38 (29409787) 2
40 (23220507) 3
MRI pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 6 2 0 0 1 0 0 0
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 5 5 0 0 1 0 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 4 3 0 0 1 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 4 4 0 0 1 0 0 0
Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy voiding cystourethrography Usually appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 7 7 1 0 0 0 5 1 1 3 3
References Study Quality
14 (11445475) 2
25 (31307659) 3
60 (16813912) 3
US pelvis transperineal May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 7 4 0 2 1
References Study Quality
54 (25854801) 2
67 (12905521) 4
68 (26291686) 4
59 (28102588) 2
66 (21512829) 4
69 (24557982) 4
US pelvis transvaginal May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 3 1 3 2 5 0 0 0 0
References Study Quality
67 (12905521) 4
66 (21512829) 4
74 (20949598) 4
75 (28650897) 2
76 (18726938) 3
Fluoroscopy cystocolpoproctography May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 1 0 4 8 1 0 0 0
References Study Quality
22 (21183491) 4
MR defecography May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 1 1 2 0 9 1 0 0
References Study Quality
50 (20350640) 4
63 (19450822) 3
64 (22395838) 2
65 (16298035) 3
62 (25727524) 3
61 (28083712) 3
MRI pelvis dynamic maneuvers without defecation May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 1 0 0 2 6 4 1 0 0
References Study Quality
27 (26867902) 3
15 (19188799) 3
28 (21427302) 3
37 (17954653) 4
63 (19450822) 3
64 (22395838) 2
65 (16298035) 3
12 (10194705) 3
26 (30241870) 3
62 (25727524) 3
29 (31494706) 3
US pelvis transabdominal Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 7 0 2 0 0 0 0 0
US pelvis transrectal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 4 3 0 3 1 1 0 0
References Study Quality
70 (2652866) 3
71 (3056562) 4
72 (2697451) 4
73 (2665902) 4
MRI pelvis without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 3 4 4 2 0 1 0 0 0
References Study Quality
37 (17954653) 4
63 (19450822) 3
64 (22395838) 2
65 (16298035) 3
62 (25727524) 3
61 (28083712) 3
MRI pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 6 3 1 0 0 0 0 0
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 4 3 1 1 2 0 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 4 3 1 0 1 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 4 4 1 0 1 0 0 0
Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US pelvis transrectal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 3 1 8 1 1
References Study Quality
20 (19937315) 4
96 (20814874) 4
91 (17096089) 3
92 (22350189) 3
94 (8173933) 3
95 (10201781) 3
41 (11425977) 1
97 (16328609) 3
98 (15666154) 2
93 (28674949) 2
Fluoroscopy cystocolpoproctography Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 0 1 1 2 4 6
References Study Quality
22 (21183491) 4
82 (7607027) 3
11 (10397095) 3
81 (8756846) 4
83 (10189475) 3
MR defecography Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 2 0 1 5 5
References Study Quality
86 (21257836) 2
27 (26867902) 3
31 (23541093) 3
30 (11997560) 2
33 (20544342) 4
15 (19188799) 3
28 (21427302) 3
90 (16801366) 3
87 (20219700) 2
23 (24506228) 1
26 (30241870) 3
32 (26880893) 3
34 (29944912) 3
35 (28386692) 4
36 (11496081) 4
88 (27459133) 4
29 (31494706) 3
US pelvis transperineal May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 1 5 3 3 1 0 0
References Study Quality
51 (18409183) 2
52 (19438878) 2
53 (18256847) 3
MRI pelvis dynamic maneuvers without defecation May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 0 0 2 6 2 1 2 0
References Study Quality
27 (26867902) 3
15 (19188799) 3
28 (21427302) 3
26 (30241870) 3
29 (31494706) 3
MRI pelvis without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 3 2 2 3 2 1 1 0 0
References Study Quality
41 (11425977) 1
US pelvis transabdominal Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 3 1 0 1 1 0 0 0
US pelvis transvaginal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 4 1 5 1 0 0 0 0
References Study Quality
99 (22374273) 4
Fluoroscopy voiding cystourethrography Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 8 3 2 1 0 0 0 0 0
MRI pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 3 3 2 2 3 0 1 0 0
CT pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 6 3 0 1 1 0 0 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 6 2 0 0 1 0 0 0
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 7 2 0 0 1 0 0 0
Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MR defecography Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 4 1 7 1 0
References Study Quality
108 (16844938) 4
37 (17954653) 4
40 (23220507) 3
107 (27399245) 4
MRI pelvis dynamic maneuvers without defecation Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 3 3 7 1 0
References Study Quality
108 (16844938) 4
37 (17954653) 4
40 (23220507) 3
107 (27399245) 4
MRI pelvis without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 3 10 1
References Study Quality
108 (16844938) 4
111 (15710136) 4
37 (17954653) 4
110 (16710883) 3
40 (23220507) 3
107 (27399245) 4
US pelvis transperineal May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 0 0 8 2 0 1 2
References Study Quality
114 (24407819) 4
47 (26663519) 2
113 (27610378) 3
116 (28079568) 3
117 (27925696) 3
118 (29947126) 4
US pelvis transvaginal May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 1 8 2 2 1 0
References Study Quality
119 (25620321) 4
120 (23229417) 2
122 (23818418) 3
123 (28145918) 4
121 (23727223) 3
Fluoroscopy voiding cystourethrography May be appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 1 3 7 1 2 0 0
References Study Quality
14 (11445475) 2
MRI pelvis without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 8 5 0 1 0
References Study Quality
111 (15710136) 4
37 (17954653) 4
100 (23521482) 4
109 (8632544) 3
40 (23220507) 3
107 (27399245) 4
US pelvis transabdominal Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 6 2 0 0 0 0 0 0
US pelvis transrectal Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 5 2 6 0 1 0 0 0 0
Fluoroscopy cystocolpoproctography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 6 3 5 0 0 0 0 0 0
CT pelvis with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 2 9 0 1 0 0 0 0
References Study Quality
100 (23521482) 4
107 (27399245) 4
CT pelvis without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 5 0 0 0 0 0 0 0
References Study Quality
100 (23521482) 4
107 (27399245) 4
CT pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 7 0 0 0 0 0 0 0
References Study Quality
100 (23521482) 4
107 (27399245) 4
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.