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Appropriateness Criteria

Variant 1: Child assigned male at birth (AMB). Younger than 2 months of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US kidneys and bladder Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 0 2 4 5 6
References Study Quality
31 (24515519) 3
30 (12172827) 3
29 (14669099) 3
28 (12023172) 3
27 (12164349) 3
26 (11371951) 3
25 (10103346) 4
24 (25963184) 3
23 (24858915) 2
22 (27707778) 3
21 (24104957) 4
16 (-3192173) 4
11 (23378477) 4
10 (24308231) 4
9 (10835062) 4
8 (25155732) 4
Voiding urosonography May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 4 1 6 3 2 1 0
References Study Quality
41 (27940735) 4
40 (26597418) 3
39 (24442338) 2
38 (21523607) 4
37 (22211993) 2
36 (22580901) 4
35 (29019761) 4
34 (9885609) 2
33 (17639371) 4
32 (11687676) 2
Fluoroscopy voiding cystourethrography May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 1 2 1 5 6 1 1 0
References Study Quality
18 (28408468) 3
17 (8320616) 3
16 (-3192173) 4
11 (23378477) 4
10 (24308231) 4
9 (10835062) 4
8 (25155732) 4
Nuclear medicine cystography Usually not appropriate Limited ☢☢ 0.03-0.3 mSv [ped] 2 2 8 2 2 0 4 1 1 0 0
References Study Quality
19 (16732797) 3
20 (-3196026) 4
MRI abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 0 3 1 0 0 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 1 1 2 0 0 0 0
MRU without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 1 0 1 1 0 0 0
CT abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 3 1 0 0 1 0 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 2 0 1 0 0 0 0 0
DMSA renal scan Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 3 2 7 1 3 2 0 0 0
References Study Quality
16 (-3192173) 4
15 (10321827) 4
14 (22698573) 4
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 16 1 0 0 1 0 0 0 0
CTU without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 13 2 1 1 1 0 0 0 0
Variant 2: Child assigned female at birth (AFAB). Younger than 2 months of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US kidneys and bladder Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 0 2 5 4 6
References Study Quality
31 (24515519) 3
30 (12172827) 3
29 (14669099) 3
28 (12023172) 3
27 (12164349) 3
26 (11371951) 3
25 (10103346) 4
24 (25963184) 3
22 (27707778) 3
21 (24104957) 4
16 (-3192173) 4
11 (23378477) 4
10 (24308231) 4
9 (10835062) 4
8 (25155732) 4
Voiding urosonography May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 1 2 9 2 3 0 0
References Study Quality
40 (26597418) 3
39 (24442338) 2
38 (21523607) 4
37 (22211993) 2
36 (22580901) 4
35 (29019761) 4
34 (9885609) 2
33 (17639371) 4
32 (11687676) 2
Fluoroscopy voiding cystourethrography May be appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 2 3 8 3 0 1 0
References Study Quality
9 (10835062) 4
18 (28408468) 3
42 (3492872) 4
Nuclear medicine cystography May be appropriate Limited ☢☢ 0.03-0.3 mSv [ped] 4 4 0 1 3 8 3 2 0 0 0
References Study Quality
19 (16732797) 3
42 (3492872) 4
MRI abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 1 1 1 0 0 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 1 1 1 0 0 0 0
MRU without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 1 2 0 0 0 0
CT abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 3 0 0 0 1 0 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 0 1 0 0 0 0 0
DMSA renal scan Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 3 1 6 3 3 2 0 0 0
References Study Quality
16 (-3192173) 4
15 (10321827) 4
14 (22698573) 4
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 16 1 0 0 1 0 0 0 0
CTU without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 13 4 1 0 0 0 0 0 0
Variant 3: Child. 2 months to 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US kidneys and bladder Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 1 0 0 0 4 5 2 6
References Study Quality
77 (12592126) 1
76 (17024392) 2
75 (17520245) 2
74 (15241674) 1
73 (12529459) 2
72 (15102643) 3
71 (16502071) 3
70 (16565830) 3
69 (15643258) 3
68 (10799427) 3
67 (11511988) 2
66 (21074813) 2
65 (19593590) 3
64 (-3196024) 3
49 (11801699) 2
41 (27940735) 4
1 (21873693) 4
31 (24515519) 3
30 (12172827) 3
29 (14669099) 3
28 (12023172) 3
27 (12164349) 3
26 (11371951) 3
25 (10103346) 4
16 (-3192173) 4
Voiding urosonography May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 2 1 7 5 2 0 0
References Study Quality
40 (26597418) 3
39 (24442338) 2
38 (21523607) 4
37 (22211993) 2
36 (22580901) 4
35 (29019761) 4
34 (9885609) 2
33 (17639371) 4
32 (11687676) 2
Fluoroscopy voiding cystourethrography May be appropriate Strong ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 1 12 3 0 1 0
References Study Quality
62 (20494369) 1
61 (20650499) 4
60 (15258842) 4
59 (16791609) 2
58 (16491412) 2
50 (12700963) 4
43 (24795142) 1
41 (27940735) 4
16 (-3192173) 4
7 (21059720) M
Nuclear medicine cystography May be appropriate Limited ☢☢ 0.03-0.3 mSv [ped] 5 5 1 0 1 2 9 4 0 0 0
References Study Quality
9 (10835062) 4
48 (10855622) M
63 (25030771) 3
19 (16732797) 3
42 (3492872) 4
MRI abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 2 1 0 0 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 0 1 2 0 0 0 0
MRU without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 2 0 1 0 0 1 0 0
CT abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 2 0 1 0 0 0 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 1 0 1 0 0 0 0 0
DMSA renal scan Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 4 3 9 0 0 1 0 0 0
References Study Quality
57 (24366989) 3
56 (21669900) M
55 (1331546) 4
54 (18490378) 1
53 (18977988) 1
52 (17188624) 3
51 (18035134) 2
50 (12700963) 4
49 (11801699) 2
48 (10855622) M
47 (16082551) 2
46 (11152787) 2
45 (22998917) 3
5 (21199053) 4
16 (-3192173) 4
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 16 1 0 1 0 0 0 0 0
CTU without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 13 3 1 1 0 0 0 0 0
Variant 4: Child. Older than 6 years of age. First febrile urinary tract infection with appropriate response to medical management. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US kidneys and bladder May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 2 1 8 3 1 1 1
References Study Quality
16 (-3192173) 4
Voiding urosonography May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 2 0 5 3 3 3 1 0 0
References Study Quality
16 (-3192173) 4
Fluoroscopy voiding cystourethrography Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 5 3 4 3 1 0 2 0 0
References Study Quality
16 (-3192173) 4
Nuclear medicine cystography Usually not appropriate Limited ☢☢ 0.03-0.3 mSv [ped] 1 1 9 5 2 0 0 1 0 0 0
References Study Quality
16 (-3192173) 4
MRI abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 3 0 0 2 0 1 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 1 2 0 0 0
MRU without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 3 0 0 1 1 1 0 0
CT abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 3 0 0 1 0 1 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 0 2 0 0 0 0 0
DMSA renal scan Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 9 6 0 1 0 1 0 0 0
References Study Quality
16 (-3192173) 4
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 1 1 0 0 1 0 0 0
CTU without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 13 2 1 0 1 1 0 0 0
Variant 5: Child. Atypical or recurrent febrile urinary tract infections. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US kidneys and bladder Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 4 7 7
References Study Quality
84 (23525769) 4
82 (23790712) 4
77 (12592126) 1
76 (17024392) 2
75 (17520245) 2
74 (15241674) 1
73 (12529459) 2
72 (15102643) 3
71 (16502071) 3
70 (16565830) 3
69 (15643258) 3
68 (10799427) 3
67 (11511988) 2
66 (21074813) 2
65 (19593590) 3
64 (-3196024) 3
49 (11801699) 2
41 (27940735) 4
31 (24515519) 3
30 (12172827) 3
29 (14669099) 3
28 (12023172) 3
27 (12164349) 3
26 (11371951) 3
25 (10103346) 4
16 (-3192173) 4
Voiding urosonography Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 3 4 2 7 0
References Study Quality
40 (26597418) 3
39 (24442338) 2
38 (21523607) 4
37 (22211993) 2
36 (22580901) 4
35 (29019761) 4
34 (9885609) 2
33 (17639371) 4
32 (11687676) 2
Fluoroscopy voiding cystourethrography Usually appropriate Moderate ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 7 7 1 0 0 1 4 3 1 5 3
References Study Quality
1 (21873693) 4
16 (-3192173) 4
41 (27940735) 4
43 (24795142) 1
83 (26475948) 4
Nuclear medicine cystography May be appropriate Limited ☢☢ 0.03-0.3 mSv [ped] 5 5 1 0 0 5 6 4 0 1 0
References Study Quality
19 (16732797) 3
CT abdomen and pelvis with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 3 2 3 4 5 1 0 0 0
References Study Quality
83 (26475948) 4
82 (23790712) 4
81 (19782999) 4
80 (18845984) 3
DMSA renal scan May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 1 0 2 3 6 2 1 2 0
References Study Quality
83 (26475948) 4
MRI abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 3 0 3 0 2 0 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 0 2 1 0 1 0 0
MRU without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 9 2 2 0 4 0 1 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 5 0 1 0 0 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 12 4 1 0 0 1 0 0 0
CTU without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 10 2 1 2 2 1 0 0 0
Variant 6: Child. Established vesicoureteral reflux. Follow-up imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US kidneys and bladder Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 1 2 6 8
References Study Quality
72 (15102643) 3
71 (16502071) 3
70 (16565830) 3
69 (15643258) 3
68 (10799427) 3
67 (11511988) 2
61 (20650499) 4
31 (24515519) 3
29 (14669099) 3
Voiding urosonography Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 2 7 5 2
References Study Quality
40 (26597418) 3
39 (24442338) 2
38 (21523607) 4
37 (22211993) 2
36 (22580901) 4
35 (29019761) 4
34 (9885609) 2
33 (17639371) 4
32 (11687676) 2
Fluoroscopy voiding cystourethrography Usually appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 8 8 0 0 0 0 1 1 3 7 6
References Study Quality
61 (20650499) 4
Nuclear medicine cystography Usually appropriate Limited ☢☢ 0.03-0.3 mSv [ped] 7 7 1 0 0 0 5 2 6 4 0
References Study Quality
61 (20650499) 4
MRU without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 2 0 2 7 3 2 0 0
References Study Quality
87 (16786563) 3
86 (24500707) 3
DMSA renal scan May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 0 0 1 5 5 3 3 1
References Study Quality
61 (20650499) 4
85 (28681079) 3
MRI abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 0 1 1 1 1 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 0 1 2 1 0 0 0
CT abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 1 0 1 1 0 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 2 0 1 0 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 15 1 1 0 0 0 1 0 0
CTU without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 13 2 0 0 3 0 0 0 0
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.