H. Urological, Adrenal and Genitourinary Systems

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CLINICAL PROBLEM

INVESTIGATION

RECOMMENDATION
{GRADE}

COMMENT
Haematuria macro- or microscopic H1 US + AXR
IVU		 Indicated
Indicated		 [B]
[B]		 There is a wide variation in local policy. Imaging strategies should be agreed with the local nephrologists and urologists. In many centres US + AXR are the initial studies, but if negative, IVU is still indicated in patients with continuing macroscopic haematuria or in the over 40s with microscopic haematuria. Conversely, patients in whom IVU and cystoscopy are normal who continue to bleed should undergo US, as IVU can fail to show a renal tumour and US will occasionally demonstrate a bladder lesion not seen at cystoscopy.
Hypertension (without evidence of renal disease) H2 IVU Not indicated [A] IVU is insensitive for renal artery stenosis. See H3.
Hypertension: in the young adult or in patients unresponsive to medication H3 US kidneys Indicated [B] To assess relative renal size and parenchymal pattern. Doppler US is not sensitive enough for use as a screening tool.
NM renogram Specialised investigation [C] Captopril renography is used in some centres to screen for functional renal artery stenosis.
Angiography (DSA, CTA or MRA) Specialised investigation [C] To show stenosis if surgery or angioplasty is considered as a possible treatment.
Renal failure H4 US + AXR Indicated [B] For renal size, structure, obstruction, etc. N.B. a normal US does not exclude obstruction.
NM Indicated [B] When appropriate, renography can assess renal perfusion and function.
Renal colic, loin pain H5 IVU Indicated [B] As an emergency examination whilst the pain is present, as radiological signs disappear rapidly after passage of a stone. Delayed films (up to 24 hrs) may be needed to show the site of obstruction. A plain film on its own is of little value. Some centres are now using spiral CT for initial diagnosis.
US + AXR Not indicated routinely [B] But of use in those with contraindications to contrast medium or irradiation. Patients need to be well hydrated in this case.
Renal calculi (in the absence of acute colic) H6 US + AXR Indicated [C] AXR alone may be appropriate follow-up for previously demonstrated calculi after an uncomplicated acute attack. An IVU may be required before treatment to show anatomy.
?Renal mass H7 US Indicated [B] US is good at distinguishing between cystic and solid masses.
AXR + IVU Not indicated [C] CT or MRI preferable for staging and assessing complex lesions shown at US.
Prostatism H8 US
IVU		 Indicated
Not indicated		 [B]
[B]		 US can assess upper tract and bladder volumes before and after voiding, preferably with flow rates. It can also show bladder calculi. Transrectal US is not routinely indicated.
?Prostatic malignancy H9 US Specialised investigation [B] Transrectal US with guided biopsies after clinical examination. Some interest in MRI and PET here.
Urinary retention H10 US
IVU		 Indicated
Not indicated		 [C]
[C]		 US to evaluate the upper tracts (after catheterisation and relief of bladder distension), particularly if urea levels remain raised.
?Scrotal mass or pain H11 US Indicated [B] Allows differentiation of testicular from extra-testicular lesions.
?Testicular torsion H12 US Not indicated routinely [C] Torsion is a clinical diagnosis and imaging investigations must not delay the priority that must be given to surgical exploration. Doppler US can be used, when clinical findings are equivocal in the post-pubertal testis.
NM Specialised investigation [C] NM techniques can assist with this diagnosis but prompt results essential.
Urinary tract infection in adults (For Children see Section M) H13 US + AXR or IVU Not indicated routinely [C] The majority do not need investigation unless there are recurrent infections, renal colic or failure to respond to antibiotics. Slightly lower threshold to investigate male patients.
N.B. This does not apply to children.
Adrenal medullary tumours H14 CT or MRI Specialised investigation [B] Whilst US may identify lesions of this type, CT and MRI provide the best anatomical delineation. Imaging is rarely indicated in the absence of biochemical evidence of such tumours.
NM Specialised investigation [B] MIBG locates functioning tumours and is particularly useful for ectopic sites and metastases.
Adrenal cortical lesions, Cushing's and Conn's disease and syndrome H15 CT, NM or MRI Specialised investigation [B] Local advice on the most appropriate examination should be sought. Both CT and MRI can differentiate between the different lesions. NM can distinguish between functioning and non-functioning adenomas. So too can various MRI techniques.

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