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Abstract

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The Canadian Association of Radiologists (CAR) Genitourinary Expert Panel is made up of physicians from the disciplines of radiology, emergency medicine, family medicine, nephrology, and urology, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 22 clinical/diagnostic scenarios, a rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 30 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 65 recommendation statements across the 22 scenarios (2 scenarios point to the CAR Obstetrics and Gynecology Diagnostic Imaging Referral Guideline). This guideline presents the methods of development and the referral recommendations for haematuria, hypertension, renal disease (or failure), renal colic, renal calculi in the absence of acute colic, renal lesion, urinary tract obstruction, urinary tract infection, scrotal mass, or pain, including testicular torsion, adrenal mass, incontinence, urgency, and frequency, chronic pelvic pain, elevated PSA, infertility, and pelvic floor.

Keywords

genitourinary diagnostic imaging referrals guideline recommendations

Introduction

Beginning in March 2023, an Expert Panel (EP) made up of physicians from the disciplines of radiology, emergency medicine, family medicine, nephrology, and urology, a patient advisor, and an epidemiologist/guideline methodologist met to develop a new set of recommendations specific to referral pathways for genitourinary conditions. Through discussion (via a virtual meeting) followed by offline communication, the EP developed a list of 22 clinical/diagnostic scenarios to be covered by this guideline. These recommendations are intended primarily for referring clinicians (eg, family physicians, specialty physicians, nurse practitioners); however, they may also be used by radiologists, individuals/patients, and patient representatives.

Our methods describing the guideline development process, including the rapid scoping review to identify the evidence base, has been published in CMAJ Open¹ and an editorial to this series of guideline publications is available in CARJ.² The application of well-established scoping review and rapid review guidance (JBI,³ Cochrane Handbook,⁴ Cochrane Rapid Review Methods Group⁵) and guideline methodology (ie, Grading of Recommendations Assessment, Development, and Evaluation or GRADE^6,7) were used to identify the evidence-base and to guide the Expert Panel in determining the strength and direction of the recommendations for each clinical scenario (Table 1). The quality of conduct and reporting of the included guidelines identified in the scoping review were evaluated with the AGREE-II checklist,⁸ using a modified scoring system. In instances where guidelines were lacking, expert consensus was used to develop the recommendation. Contextualization to the Canadian health care system was considered for each recommendation, with discussion around the factors found in the Evidence to Decision framework in GRADE for guidelines (eg, balance of desirable and undesirable outcomes, values and preferences, resources implications).⁷

Table 1.

Recommendation Text, Symbol, and Interpretation.

Recommendation	AGAINST	FOR
STRONG	Strong, against “we recommend against” (↓↓) • All or almost all informed people would not recommend/choose the course of action and only a small proportion would.	Strong, for “we recommend” (↑↑) • All or almost all informed people would recommend/choose the course of action and only a small proportion would not. • Request discussion if the intervention is not offered.
CONDITIONAL	Conditional, against “we suggest against” (↓) • Most informed people would not recommend/choose the course of action, but a substantial number would. • This may be conditional upon patient values and preferences, the resources available or the setting in which the intervention will be implemented.	Conditional, for “we suggest” (↑) • Most informed people would recommend/choose the course of action, but a substantial number would not. • This may be conditional upon patient values and preferences, the resources available or the setting in which the intervention will be implemented.

Note. Down arrows are red and Up arrows are green when available in colour.

Created using the guidance provided in Andrews et al.⁶

A systematic search for guidelines (with an a priori defined inclusion criteria) was run in Medline and Embase on May 29, 2023. The search was limited to publications from 2018 onward (Supplemental Appendix 1). Supplemental searching included the following national radiology and/or guideline groups: the American College of Radiology, the American Urological Association, the Canadian Urological Association, the National Institute for Health and Care Excellence, the Society of Obstetricians and Gyneacologists, and the Royal College of Radiologists 8th Edition (2017). Recommendations for each clinical scenario were formulated over 2 virtual meetings on January 20 and February 12, 2024. External review and feedback were obtained from radiologists, a nuclear medicine radiologist, an emergency physician, a family physician, and nurse practitioners. The full guideline can be found on the CAR website (www.car.ca).

Results

Systematic Scoping Review

A total of 4205 records were identified through the electronic database and 18 additional records were added from the supplemental search. Thirty guidelines, plus 2 companion papers, were included (Figure 1). All potentially relevant guidelines were published in English. A list of excluded records with justifications for exclusion is available upon request. Most guidelines were rated as moderate or high quality, using the modified AGREE-II checklist⁸ (Supplemental Appendix 2). The number of guidelines included per clinical/diagnostic scenario ranged from 1 to 6, with a median of 3 guidelines per clinical scenario.

Figure 1.

PRISMA flow diagram.

Recommendations

Additional details of the included guidelines, including which imaging modalities (eg, computed tomography [CT], magnetic resonance imaging [MRI], radiograph [XR], ultrasound [US]) that were discussed can be found in Supplemental Appendix 3.

A guideline is intended to guide and not be an absolute rule. Medical care is complex and should be based on evidence, a clinician’s expert judgment, the patient’s circumstances, values, preferences, and resource availability. Not all imaging modalities are available in all clinical environments, particularly in rural or remote areas of Canada. Decisions about patient transfer, use of alternative imaging or serial clinical examination and observation can be complex and difficult. Therefore, the expected benefits of recommended imaging, risks of travel, patient preference, and other factors must be considered. The guideline recommendations are designed to assist the choice of imaging modality in situations where it is deemed clinically necessary to obtain imaging.

Unless the panel agreed a specific protocol is required to optimize patient care/diagnosis, the recommendations do not specify when contrast should or should not be used, as this decision may vary based on clinical presentation, regional practice preferences, preference of the referring clinician, radiologist and/or the patient, and resource availability.

We reviewed relevant recommendations related to the 22 clinical/diagnostic scenarios previously published by radiology and specialty societies, including: the Canadian Association of Radiologists,⁹ the American College of Emergency Physicians,¹⁰ the American College of Radiology,^11-20 the American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction,²¹ the American Urological Association/Canadian Urological Society/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction,²² the Canadian Urological Association,^23-29 the European Association of Urology,^30-32 the German Association of Scientific Medical Societies in Germany,³³ Hypertension Canada,³⁴ National Comprehensive Cancer Network,³⁵ the National Institute for Health and Care Excellence,^36-38 the Royal College of Radiologists,³⁹ and the Urethral Structures Guideline Amendement.⁴⁰

Recommendations are presented in Table 2.

Table 2.

Genitourinary Recommendations.

Clinical/diagnostic scenario and recommendations
GU01. Haematuria
GU01A. Gross haematuria^9,11,39
1. In younger adults with gross haematuria, we recommend US as the initial imaging modality, in conjunction with urology referral (↑↑). ↳ 1.1 If further imaging is required, we suggest CT urography as the next imaging modality (↑). ↳ 1.2 If CT urography is contraindicated, we recommend MR urography as an alternative imaging modality (↑↑). 2. In older adults with gross haematuria, we recommend CT urography as the initial imaging modality in conjunction with urology referral (↑↑). ↳ 2.1 If CT urography is contraindicated, we recommend MR urography or US as an alternative imaging modality (↑↑). Note. CT urography is equivalent to CT intravenous pyelography (CT IVP).
GU01B. Microhaematuria^9,11,21,39
1. In low-risk patients^✧ with microscopic haematuria, we recommend US as the initial imaging modality with consideration to urology referral (↑↑). 2. In high-risk adults (eg, older age, smoking history) with microhaematuria, we recommend CT urography as the initial imaging modality (↑↑). 3. In pregnant adults with microhaematuria, we recommend US as the initial imaging modality (↑↑). ↳ 3.1 If US is inconclusive, we suggest MR urography as an alternative imaging modality (↑). ^✧no history of recent vigorous exercise, infection or viral illness, present or recent menstruation, renal parenchymal disease
GU02. Hypertension, in absence of renal disease (or kidney failure)
GU02A. Responsive to medication^9,34
1. In adults with hypertension who are responsive to medication, we recommend no imaging (↓↓).
GU02B. Unresponsive to medication^9,34,39
1. In adults with hypertension who are unresponsive to medication,^✧ we suggest against US Doppler as the initial imaging modality (↓). 2. In adults with hypertension who are unresponsive to medication,^✧ we recommend US as the initial imaging modality to assess for renal size and/or size discrepancy (EPc). ↳ 2.1 If further imaging is indicated clinically, we recommend CTA as the initial imaging modality (↑↑). ↳ 2.2 If CTA is contraindicated, we suggest MRA or NM as an alternative imaging modality (↑). ^✧≥3 medications³⁴
GU03. Renal disease (or failure)
GU03A. Acute kidney injury (or failure)^9,12,36,39
Renal and pre-renal causes of acute renal failure are more common than post-renal etiologies (eg, stones) and should be excluded clinically and biochemically prior to consideration of any imaging. 1. In adults with acute kidney injury (or failure), we recommend US as the initial imaging modality (↑↑). ↳ 1.1 If US is unavailable, we suggest CT as an alternative imaging modality (↑).
GU03B. Chronic kidney disease^9,12,39
1. In adults with suspected chronic kidney disease, we recommend US as the initial imaging modality (↑↑). ↳ 1.1 If characterization of US-detected hydronephrosis is needed, we suggest CT abdomen and pelvis as the next imaging modality (↑). ↳ 1.2 If contrast-enhanced CT is contraindicated, we suggest MRI as an alternative imaging modality (↑). ↳ 1.3 If MRI is unavailable, we suggest non-contrast CT as an alternative imaging modality (↑). 2. In adults with suspected renovascular cause of chronic kidney disease, see GU02. Hypertension, in absence of renal disease (or failure). For information on the use of gadolinium-based contrast agents in kidney disease, see the 2019 CAR guideline.⁴¹
GU04. Renal colic^{9,10,13,23,24,30,39}
1. In younger adults with suspected renal colic, we recommend US ± abdominal XR as the initial imaging modalities (↑↑). ↳ 1.1 If further imaging is required, we recommend CT as the next imaging modality (↑↑). 2. In older adults with suspected renal colic, we recommend CT as the initial imaging modality (↑↑). ↳ 2.1 If CT is unavailable, we recommend US and/or abdominal XR as an alternative imaging modality (↑↑). 3. In pregnant adults with suspected renal colic, we recommend US as the initial imaging modality (↑↑).
GU05. Renal calculi in absence of renal colic^9,37,39
1. In patients with known renal calculi in the absence of acute colic, we recommend US (↑↑). ↳ 1.1 If US is unavailable, we recommend XR (↑↑).
GU06. Renal lesion^{9,14,25-27,39}
1. In adults with suspected solid renal lesion(s) incidentally detected on US or CT requiring further characterization, we recommend a multi-phase CT abdomen as the initial imaging modality (↑↑). ↳ 1.1 If further imaging is required, we suggest MRI abdomen as the next imaging modality (↑). ↳ 1.2 If CT and MRI are contraindicated, we recommend contrast-enhanced US as an alternative (↑↑). 2. In adults with suspected cystic renal lesion(s) incidentally detected requiring further characterization, we recommend US as the initial imaging modality (↑↑). ↳ 2.1 If further imaging is required, we recommend multi-phase CT abdomen (↑↑). ↳ 2.2 If CT is contraindicated, we recommend MRI abdomen as an alternative (↑↑). ↳ 2.3 If MRI is contraindicated, we recommend contrast-enhanced US as an alternative (↑↑).
GU07. Urinary tract obstruction
GU07A. Upper (pelviectasis, hydronephrosis)^9,39
1. In adults with suspected upper urinary tract obstruction, we recommend US as the initial imaging modality (↑↑). ↳ 1.1 If further imaging is required, we recommend CT abdomen as the next imaging modality (↑↑). 2. In pregnant adults with suspected upper urinary tract obstruction, we recommend US as the initial imaging modality (↑↑). ↳ 2.1 If further imaging is required, we recommend MRI abdomen as the next imaging modality (↑↑). If clinical concern for renal colic, see GU04; If clinical concern for infection, see GU08.
GU07B. Lower (lower urinary tract syndrome)^{9,28,31,39,40}
The guideline recommendations are to assist the choice of imaging modality in situations where it is felt clinically and/or biochemically necessary to obtain imaging. If imaging is required, then: 1. In adults with male anatomy and suspected lower urinary tract obstruction, we recommend against imaging in the absence of renal impairment (↓↓). ↳ 1.1 In patients with renal impairment, we recommend US (↑↑). 2. In adults with male anatomy and treatment resistant lower urinary tract obstruction, we suggest US in conjunction with urology referral (↑). 3. In adults with female anatomy and suspected lower urinary tract obstruction, we recommend US in conjunction with specialist referral (↑↑). If clinical concern for pelvic floor dysfunction, see GU15.
GU08. Urinary tract infection (UTI)
GU08A. Acute^9,33,39
1. In adults with acute urinary tract infection, we recommend no imaging (↓↓). For acute urinary tract infection in the paediatric population, see CAR Pediatric Guideline.
GU08B. Post-treatment failure (pyelonephritis)^9,15
1. In adults with suspected acute pyelonephritis, we recommend against imaging (↓↓). 2. In adults with suspected abscess or other complications of acute pyelonephritis, we recommend US or CT abdomen and pelvis as the initial imaging modality (↑↑). 3. In pregnant adults with suspected abscess or other complications of acute pyelonephritis, we suggest US as the initial imaging modality (↑). ↳ 3.1 If US is indeterminate or clinical suspicion persists, we suggest MRI as the next imaging modality (↑).
GU08C. Chronic and recurrent bladder infections^9,16,22
1. In adults with female anatomy with uncomplicated recurrent lower urinary tract infections, we recommend against imaging (↓↓). 2. In patients with complicated urinary tract infections, we recommend urology referral (↑↑). For recurrent urinary tract infection in the pediatric population, see CAR Pediatric Guideline.
GU09. Scrotal mass or pain, including testicular torsion and epididymitis^9,17,18,39
1. In adults with scrotal pathology, we recommend US (↑↑). 2. In adults with scrotal pain (without trauma) and clinical concern for Fournier’s gangrene, we recommend CT and surgical referral (EPc).
GU10. Adrenal mass^19,29,35,39
1. In adults with incidentally discovered indeterminate adrenal masses, we recommend MRI or non-contrast CT as the initial imaging modality (↑↑). ↳ 1.1 If further imaging is required, we suggest adrenal washout CT as the next imaging modality (↑). ↳ 1.2 If concern for adrenal metastasis, we suggest NM (PET-CT) (↑). 2. In adults with undiagnosed suspected biochemically active tumours, we suggest MRI or CT as the initial imaging modalities (↑↑). ↳ 2.1 If further imaging is required, we suggest NM consultation (↑).
GU11. Incontinence, urgency, and frequency^32,38
1. In adults with urinary incontinence, urgency, and/or frequency, we suggest US to assess for post-void residual urine, if clinically indicated (↑). ↳ 1.1 Where post-void residual assessment is not clinically indicated, we recommend against imaging (↓↓). 2. In patients with female anatomy, to evaluate for specific causes of lower urinary tract symptoms (eg, urethral diverticulum, etc.), we suggest MRI (↑). If clinical concern for lower urinary tract obstruction, see GU07B; If clinical concern for urinary tract infection, see GU08. For urinary incontinence (Enuresis and Continual incontinence) in the paediatric population, see CAR Pediatric Guideline.
GU12. Chronic pelvic pain
GU12A. Chronic pelvic pain in females
Recommendations for this clinical scenario were covered by the Obstetrics and Gynecology Expert Panel. See CAR Obstetric and Gynecology Diagnostic Imaging Referral Guideline⁴² for more information.
GU12B. Chronic pelvic pain in males⁹
1. In adults with male anatomy with non-specific chronic pelvic pain, we suggest CT as the initial imaging modality (EPc). 2. In adults with suspected chronic prostatitis, we recommend against routine imaging (EPc). In patients with elevated PSA, see GU13.
GU13. Elevated PSA³⁹
1. In adults with persistently or markedly elevated PSA, we recommend urology referral ± MRI (↑↑). Referral for MRI may differ based on regional/local practice preference.* *Refer to Canadian Urology Association Prostate screening guideline⁴³
GU14. Infertility
Recommendations for this clinical scenario were covered by the Obstetrics and Gynecology Expert Panel. See CAR Obstetric and Gynecology Diagnostic Imaging Referral Guideline⁴² for more information.
GU15. Pelvic floor²⁰
1. In adults with vaginal protrusion or bulge, or suspected pelvic organ prolapse, or defecatory dysfunction, we recommend MR defecography as the initial imaging modality (↑↑). ↳ 1.1 If MR defecography is unavailable, we suggest fluoroscopic defecography as an alternative imaging modality (↑). Availability and use of MR defecography and fluoroscopic defecography may vary between provinces and between regions within a province. If clinical concern for urinary dysfunction, see GU11.

Note. Strength of recommendation: ↑↑ = strong for; ↑ = conditional for; ↓ = conditional against; ↓↓ = strong against; EP = Expert Panel.

CT = computed tomography; MR/MRI = magnetic resonance/imaging; NM = nuclear medicine; PET = positron emission tomography; US = ultrasound; XR = radiograph.

Supplemental Material

sj-pdf-1-caj-10.1177_08465371241261317 – Supplemental material for Canadian Association of Radiologists Genitourinary Imaging Referral Guideline

Supplemental material, sj-pdf-1-caj-10.1177_08465371241261317 for Canadian Association of Radiologists Genitourinary Imaging Referral Guideline by Candyce Hamel, Barb Avard, Gary Brahm, Daisy Fung, Benjamin Martens, Alan Michaud, Lisa Miller, Eric Sala, Christopher J. D. Wallis and Christopher Fung in Canadian Association of Radiologists Journal

Footnotes

Acknowledgements

We would like to thank: Becky Skidmore for creating the search strategies for the systematic scoping review, and the following individuals on the Diagnostic Imaging Referral Guidelines Working Group and external stakeholders for providing feedback on the guideline (listed alphabetically): Alanna Coleman (Nurse Practitioners Association of Canada), Noel Corser (Family physician), Sangeet Ghai (Radiologist), Stephanie Henry (Nurse Practitioners Association of Canada), Ryan Margau (WG co-chair, Radiologist), Paul Pageau (WG co-chair, Emergency medicine physician), Shirin Vellani (Nurse Practitioners Association of Canada), Jeffrey Wagner (Nuclear medicine radiologist), and Kaitlin Zaki-Metias (Radiologist).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Canadian Medical Association.

ORCID iDs

Candyce Hamel

Daisy Fung

Alan Michaud

Christopher J. D. Wallis

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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