Revised 2019

American College of Radiology

ACR Appropriateness Criteria®
Hematuria

Variant 1: Microhematuria. No risk factors, or history of recent vigorous exercise, or presence of

infection, or viral illness, or present or recent menstruation. Initial imaging.

Procedure Appropriateness Category Relative Radiation Level

CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢

US kidneys and bladder retroperitoneal Usually Not Appropriate O
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without and with IV
Usually Not Appropriate ☢☢☢☢
contrast
CTU without and with IV contrast Usually Not Appropriate ☢☢☢☢
MRI abdomen and pelvis without and with IV
Usually Not Appropriate O
contrast
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
MRU without and with IV contrast Usually Not Appropriate O
Arteriography kidney Usually Not Appropriate ☢☢☢
Radiography abdomen and pelvis (KUB) Usually Not Appropriate ☢☢
Radiography intravenous urography Usually Not Appropriate ☢☢☢

Variant 2: Microhematuria. Patients with risk factors, without any of the following: history of recent
vigorous exercise, or presence of infection or viral illness, or present or recent menstruation,
or renal parenchymal disease. Initial imaging.

Procedure Appropriateness Category Relative Radiation Level

CTU without and with IV contrast Usually Appropriate ☢☢☢☢

MRU without and with IV contrast May Be Appropriate O
CT abdomen and pelvis without and with IV
May Be Appropriate ☢☢☢☢
contrast
CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢
US kidneys and bladder retroperitoneal May Be Appropriate O
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢
MRI abdomen and pelvis without and with IV
Usually Not Appropriate O
contrast
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
Radiography abdomen and pelvis (KUB) Usually Not Appropriate ☢☢
Arteriography kidney Usually Not Appropriate ☢☢☢
Radiography intravenous urography Usually Not Appropriate ☢☢☢

ACR Appropriateness Criteria® 1 Hematuria

Variant 3: Microhematuria. Pregnant patient. Initial imaging.

Procedure Appropriateness Category Relative Radiation Level

US kidneys and bladder retroperitoneal Usually Appropriate O

MRU without IV contrast May Be Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without and with IV
Usually Not Appropriate ☢☢☢☢
contrast
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢
CTU without and with IV contrast Usually Not Appropriate ☢☢☢☢
Arteriography kidney Usually Not Appropriate ☢☢☢
MRI abdomen and pelvis without and with IV
Usually Not Appropriate O
contrast
MRU without and with IV contrast Usually Not Appropriate O
Radiography abdomen and pelvis (KUB) Usually Not Appropriate ☢☢
Radiography intravenous urography Usually Not Appropriate ☢☢☢

Variant 4: Gross hematuria. Initial imaging.

Procedure Appropriateness Category Relative Radiation Level

CTU without and with IV contrast Usually Appropriate ☢☢☢☢

MRU without and with IV contrast Usually Appropriate O
CT abdomen and pelvis without and with IV
May Be Appropriate ☢☢☢☢
contrast
MRI abdomen and pelvis without and with IV
May Be Appropriate O
contrast
MRI abdomen and pelvis without IV contrast May Be Appropriate O
US kidneys and bladder retroperitoneal May Be Appropriate O
CT abdomen and pelvis with IV contrast May Be Appropriate ☢☢☢
CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢
Radiography abdomen and pelvis (KUB) Usually Not Appropriate ☢☢
Arteriography kidney Usually Not Appropriate ☢☢☢
Radiography intravenous urography Usually Not Appropriate ☢☢☢

ACR Appropriateness Criteria® 2 Hematuria

 HEMATURIA

Expert Panel on Urological Imaging: Darcy J. Wolfman, MD a; Jamie Marko, MD, MSb; Paul Nikolaidis, MDc;
Gaurav Khatri, MDd; Vikram S. Dogra, MDe; Dhakshinamoorthy Ganeshan, MBBSf; Stanley Goldfarb, MDg;
John L. Gore, MD, MSh; Rajan T. Gupta, MDi; Marta E. Heilbrun, MD, MSj; Andrej Lyshchik, MD, PhDk;
Andrei S. Purysko, MDl; Stephen J. Savage, MDm; Andrew D. Smith, MD, PhDn; Zhen J. Wang, MDo;
Jade J. Wong-You-Cheong, MDp; Don C. Yoo, MDq; Mark E. Lockhart, MD, MPH.r
Summary of Literature Review
Introduction/Background
Hematuria has a prevalence rate of 2% to 31% in the population [1] and is therefore a common reason patients are
referred for imaging of the urinary tract. This document summarizes the initial imaging approach for these patients.
Follow-up of normal or abnormal initial imaging findings is beyond the scope of this document. All patients
diagnosed with microhematuria should undergo a thorough history, physical examination, urinalysis, and serologic
testing prior to any initial imaging. Further, many patients should undergo cystoscopy in addition to any imaging
evaluation [2]. For children with hematuria, see the ACR Appropriateness Criteria® topic on “Hematuria-Child”
[3].
Hematuria is characterized as either microhematuria or gross hematuria. Microhematuria is defined by the American
Urological Association as 3 or more red blood cells per high power field on microscopic evaluation of urinary
sediment from “one properly collected, noncontaminated urinalysis with no evidence of infection for which a
combination of microscopic urinalysis and dipstick excludes other abnormalities such as pyuria, bacteriuria, and
contaminants” [4]. Gross hematuria is defined as hematuria visible to the physician or patient.
Causes of hematuria can arise from anywhere along the urinary tract and are generally divided into nephrogenic
and urogenic causes. Renal parenchymal disease is the most common benign nephrogenic cause of hematuria [1].
Common benign urogenic causes of hematuria include urolithiasis, infection, and benign prostatic hypertrophy [1].
Malignant causes can occur anywhere in the urinary tract and are the main entity that must be excluded during the
imaging evaluation of hematuria.
The most common factors associated with development of a urinary malignancy include gross hematuria, male
gender, age >35 years, smoking, occupational exposure to chemicals, analgesic abuse, history of urologic disease,
irritative voiding symptoms, history of pelvic irradiation, chronic urinary tract infection, exposure to known
carcinogenic agents or chemotherapy, and chronic indwelling foreign body [1,2].
Gross hematuria has a high association with malignancy of up to 30% to 40%, and therefore all patients with gross
hematuria should have a full urologic workup [1]. Conversely, patients with microhematuria have a low risk of
malignancy ranging from 2.6% to 4%, and, in most patients with asymptomatic microhematuria, a cause is never
found [1,2].
Patients without risk factors and with an identified benign cause of microhematuria including vigorous exercise,
infection, trauma, menstruation, or recent urologic procedure are unlikely to gain any benefit from a complete
imaging workup of microhematuria [1,2,5,6]. Patients with suspected urinary tract infection as a cause of
microhematuria should have urine cultures performed, preferably before antibiotic therapy, to confirm an infection
[1,2]. Patients with a suspected cause of microhematuria, including interstitial cystitis or benign prostatic
hyperplasia, should have the appropriate clinical workup before undertaking imaging, including a pelvic
examination in women, a rectal examination in men, and cystoscopy [1,2,6]. Interstitial cystitis, in particular, should

a
Johns Hopkins University School of Medicine, Washington, District of Columbia. bNational Institutes of Health Clinical Center, Bethesda, Maryland. cPanel
Chair, Northwestern University, Chicago, Illinois. dPanel Vice-Chair, UT Southwestern Medical Center, Dallas, Texas. eUniversity of Rochester Medical
Center, Rochester, New York. fThe University of Texas MD Anderson Cancer Center, Houston, Texas. gUniversity of Pennsylvania School of Medicine,
Philadelphia, Pennsylvania, American Society of Nephrology. hUniversity of Washington, Seattle, Washington, American Urological Association. iDuke
University Medical Center, Durham, North Carolina. jEmory University School of Medicine, Atlanta, Georgia. kThomas Jefferson University Hospital,
Philadelphia, Pennsylvania. lCleveland Clinic, Cleveland, Ohio. mMedical University of South Carolina, Charleston, South Carolina, American Urological
Association. nUniversity of Alabama at Birmingham Medical Center, Birmingham, Alabama. oUniversity of California San Francisco School of Medicine, San
Francisco, California. pUniversity of Maryland School of Medicine, Baltimore, Maryland. qRhode Island Hospital/The Warren Alpert Medical School of Brown
University, Providence, Rhode Island. rSpecialty Chair, University of Alabama at Birmingham, Birmingham, Alabama.
The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness
Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily
imply individual or society endorsement of the final document.
Reprint requests to: publications@acr.org

ACR Appropriateness Criteria® 3 Hematuria

be considered in women with chronic pelvic pain along with microhematuria, because this diagnosis is prevalent
but often difficult to diagnose [6]. Patients with renal parenchymal disease (glomerulonephritis,
glomerulonephropathy, acute tubular necrosis, and acute kidney injury) should undergo a concurrent nephrology
evaluation, but this should not preclude further evaluation of microhematuria [1,2]. Use of anticoagulant therapy
does not alter the urologic evaluation of microhematuria [1,2].
Special Imaging Considerations
CT urography (CTU) is an imaging study that is tailored to improve visualization of both the upper and lower
urinary tracts. There is variability in the specific parameters, but it usually involves unenhanced images followed
by intravenous (IV) contrast-enhanced images, including nephrographic and excretory phases, acquired at least 5
minutes after contrast injection. Alternatively, a split-bolus technique uses an initial loading dose of IV contrast and
then obtains a combined nephrographic-excretory phase after a second IV contrast dose; some sites include arterial
phase. CTU should use thin-slice acquisition. Reconstruction methods commonly include maximum intensity
projection or 3-D volume rendering. For the purposes of this document, we make a distinction between CTU and
CT abdomen and pelvis without and with IV contrast. CT abdomen and pelvis without and with IV contrast is
defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts and without
both the precontrast and excretory phases.
MR urography (MRU) is also tailored to improve imaging of the urinary system. Unenhanced MRU relies upon
heavily T2-weighted imaging of the intrinsic high signal intensity from urine for evaluation of the urinary tract. IV
contrast is administered to provide additional information regarding obstruction, urothelial thickening, focal lesions,
and stones. A contrast-enhanced T1-weighted series should include corticomedullary, nephrographic, and excretory
phase. Thin-slice acquisition and multiplanar imaging should be obtained. For the purposes of this document, we
make a distinction between MRU and MRI abdomen and pelvis without and with IV contrast. MRI abdomen and
pelvis without and with IV contrast is defined as any protocol not specifically tailored for evaluation of the upper
and lower urinary tracts, without both the precontrast and excretory phases, and without heavily T2-weighted
images of the urinary tract.
Discussion of Procedures by Variant
Variant 1: Microhematuria. No risk factors, or history of recent vigorous exercise, or presence of infection,
or viral illness, or present or recent menstruation. Initial imaging.
Patients without risk factors and with a known benign cause of microhematuria are unlikely to gain any benefit
from a complete imaging workup of microscopic hematuria. Multiple studies have shown that patients in this
category do not derive any benefit from imaging [1,2,6,7].
Arteriography Kidney
Arteriography is not used as a first-line imaging modality for the evaluation of microhematuria. There is no relevant
literature regarding the use of arteriography for the initial evaluation of microhematuria.
CT Abdomen and Pelvis
For the purposes of this document, we make a distinction between CTU and CT abdomen and pelvis without and
with IV contrast. CT abdomen and pelvis without and with IV contrast is defined as any protocol not specifically
tailored for evaluation of the upper and lower urinary tracts and without both the precontrast and excretory phases.
CT without IV contrast may be a reasonable option in the setting of microhematuria in patients <50 years of age
[8]. There is no relevant literature regarding the use of CT with IV contrast for the initial evaluation of
microhematuria.
CTU
CTU is not useful as a first-line imaging modality for the evaluation of microhematuria in patients with no known
risk factors and with an identified benign cause of microhematuria. Lisanti et al [7] found that in 442 patients <40
years of age and without risk factors, no patient had a malignancy-related hematuria finding at CTU.
MRU
MRU is not useful as a first-line imaging modality for the evaluation of microhematuria in patients with no known
risk factors and with an identified benign cause of microhematuria. There is no relevant literature regarding the use
of MRU for the initial evaluation of microhematuria.

ACR Appropriateness Criteria® 4 Hematuria

MRI Abdomen and Pelvis
For the purposes of this document, we make a distinction between MRU and MRI abdomen and pelvis without and
with IV contrast. MRI abdomen and pelvis without and with IV contrast is defined as any protocol not specifically
tailored for evaluation of the upper and lower urinary tracts, without both the precontrast and excretory phases, and
without heavily T2-weighted images of the urinary tract. There is no relevant literature regarding the use of MRI
for the initial evaluation of microhematuria.
Radiography Abdomen and Pelvis
Conventional radiographs of the abdomen and pelvis (KUB) are not used as a first-line imaging modality for the
evaluation of hematuria. There is no relevant literature regarding the use of radiography for the initial evaluation of
microhematuria.
Radiography Intravenous Urography
IV urography (IVU) is no longer used as a first-line imaging modality for the evaluation of hematuria. There is no
relevant literature regarding the use of IVU for the initial evaluation of microhematuria.
US Kidneys and Bladder Retroperitoneal
Ultrasound (US) is not useful as a first-line imaging modality for the evaluation of microhematuria with no known
risk factors and with an identified benign cause of microhematuria.
Variant 2: Microhematuria. Patients with risk factors, without any of the following: history of recent
vigorous exercise, or presence of infection or viral illness, or present or recent menstruation, or renal
parenchymal disease. Initial imaging.
Arteriography Kidney
Arteriography is not used as a first-line imaging modality for the evaluation of microhematuria. There is no relevant
literature regarding the use of arteriography for the initial evaluation of microhematuria.
CT Abdomen and Pelvis
For the purposes of this document, we make a distinction between CTU and CT abdomen and pelvis without and
with IV contrast. CT abdomen and pelvis without and with IV contrast is defined as any protocol not specifically
tailored for evaluation of the upper and lower urinary tracts and without both the precontrast and excretory phases.
There is no relevant literature regarding the use of CT with IV contrast or CT without IV contrast in this patient
population with microhematuria. Initial studies compared CTU with other modalities but without direct comparison
to conventional contrast-enhanced CT. However, in current practice, CTU has replaced conventional CT in this
situation because of improved detection of urothelial lesions on CTU.
CTU
CTU has been shown to be the imaging study of choice for the evaluation of microhematuria because it can evaluate
both nephrogenic and urogenic causes of hematuria [1,2,9-12].
In a meta-analysis, CTU proved to be a very sensitive and specific method for the detection of urothelial malignancy
with pooled sensitivity of 96% and pooled specificity of 99% and was superior in direct comparison to IVU in terms
of sensitivity and specificity [10].
For the detection of upper tract lesions (kidneys and ureters), CTU has been shown to be superior to IVU with an
accuracy of 99.6% compared with 84.9% for IVU [12].
CTU has also been shown to be useful for the detection of lower tract lesions (bladder) [11,13]. In one study of 242
patients with microhematuria, the specificity and accuracy of CTU for the detection of lower tract lesions was 98.8%
and 97.2%, respectively [11].
In comparison with MRU, one study showed that CTU provided better visibility of the urothelial structures and
improved diagnostic confidence [14].
MRU
MRU has decreased spatial resolution compared with CTU. Also, small nonobstructive renal calculi and other
calcifications as well as small urothelial lesions may be difficult to detect at MRU [15]. However, MRI has shown
comparable accuracy to CT in the detection and characterization of renal masses [16].

ACR Appropriateness Criteria® 5 Hematuria

MRI Abdomen and Pelvis
For the purposes of this document, we make a distinction between MRU and MRI abdomen and pelvis without and
with IV contrast. MRI abdomen and pelvis without and with IV contrast is defined as any protocol not specifically
tailored for evaluation of the upper and lower urinary tracts, without both the precontrast and excretory phases, and
without heavily T2-weighted images of the urinary tract. There is no relevant literature regarding the use of routine
MRI with IV contrast in this patient population with microhematuria.
Radiography Abdomen and Pelvis
Conventional radiographs of the abdomen and pelvis (KUB) are not used as a first-line imaging modality for the
evaluation of hematuria. There is no relevant literature regarding the use of radiographs for the initial evaluation of
microhematuria.
Radiography Intravenous Urography
IVU is no longer used as a first-line imaging modality for the evaluation of hematuria. Multiple studies have shown
that IVU has a low sensitivity for the detection of renal masses and urinary tract abnormalities in general compared
with CT [9,10].
US Kidneys and Bladder Retroperitoneal
US is not used as a first-line imaging modality for the evaluation of microhematuria. One study of 141 patients
showed US had a lower sensitivity for the detection of urinary tract abnormalities compared with both CTU and
MRU [17]. However, a recent large prospective study suggests that kidney and bladder US may be adequate for
initial evaluation of microhematuria [18]. In this study, urinary cancer was diagnosed in 0.4% of patients who
presented with microscopic hematuria, and all the patients had a renal carcinoma [18].
Variant 3: Microhematuria. Pregnant patient. Initial imaging.
Pregnant patients present with microhematuria at a rate similar to nonpregnant patients, and the rate of malignancy
in this group is low [2,19].
Arteriography Kidney
Arteriography is not used as a first-line imaging modality for the evaluation of microhematuria in pregnancy. There
is no relevant literature regarding the use of arteriography for the initial evaluation of microhematuria.
CT Abdomen and Pelvis
CT is not used as a first-line imaging modality for the evaluation of microhematuria in pregnant patients secondary
to the risks of radiation exposure to the fetus. The incidence of asymptomatic microhematuria in pregnant women
is similar to nonpregnant women, and the rate of malignancy in this group is low [2].
CTU
CTU is not used as a first-line imaging modality for the evaluation of microhematuria in pregnant patients secondary
to the risks of radiation exposure to the fetus. The incidence of asymptomatic microhematuria in pregnant women
is similar to nonpregnant women, and the rate of malignancy in this group is low [2].
MRU
MRU without and with IV contrast is not used as a first-line imaging modality for the evaluation of microhematuria
in pregnant patients. The incidence of asymptomatic microhematuria in pregnant women is similar to nonpregnant
women, and the rate of malignancy in this group is low [2]. MRU without IV contrast during pregnancy is a
reasonable choice with a full workup after delivery once gynecologic bleeding and other benign causes (such as
infection) have been excluded [2].
MRI with IV contrast should be avoided in pregnant patients because of uncertainty of effects of gadolinium contrast
on the fetus. See the Safety Considerations in Pregnant Patients section below.
MRI Abdomen and Pelvis
The incidence of asymptomatic microhematuria in pregnant women is similar to nonpregnant women, and the rate
of malignancy in this group is low [2]. MRI abdomen and pelvis with and without IV contrast is not used as a first-
line imaging modality for the evaluation of microhematuria in pregnant patients. MRI abdomen and pelvis without
IV contrast is not used as a first-line imaging modality because of the absence of heavily T2-weighted images of
the urinary tract.

ACR Appropriateness Criteria® 6 Hematuria

MRI with IV contrast should be avoided in pregnant patients because of the uncertainty of effects of gadolinium
contrast on the fetus. See the Safety Considerations in Pregnant Patients section below.
Radiography Abdomen and Pelvis
Conventional radiographs of the abdomen and pelvis (KUB) are not used as a first-line imaging modality for the
evaluation of hematuria in pregnancy. There is no relevant literature regarding the use of radiographs for the initial
evaluation of microhematuria.
Radiography Intravenous Urography
IVU is not used as a first-line imaging modality for the evaluation of microhematuria in pregnancy. There is no
relevant literature regarding the use of IVU for the initial evaluation of microhematuria.
US Kidneys and Bladder Retroperitoneal
The incidence of asymptomatic microhematuria in pregnant women is similar to nonpregnant women, and the rate
of malignancy in this group is low [2]. US during pregnancy is a reasonable choice with a full workup after delivery
once gynecologic bleeding and other benign causes (such as infection) have been excluded [2,19].
Variant 4: Gross hematuria. Initial imaging.
Arteriography Kidney
Arteriography is not used as a first-line imaging modality for the evaluation of gross hematuria. There is no relevant
literature regarding the use of arteriography for the initial evaluation of gross hematuria.
CT Abdomen and Pelvis
For the purposes of this document, we make a distinction between CTU and CT abdomen and pelvis without and
with IV contrast. CT abdomen and pelvis without and with IV contrast is defined as any protocol not specifically
tailored for evaluation of the upper and lower urinary tracts and without both the precontrast and excretory phases.
There is no relevant literature regarding the use of CT with IV contrast or CT without IV contrast in the evaluation
of gross hematuria.
CTU
The usefulness of CTU in the evaluation of gross hematuria has been mixed [11,13,20-23]. In one study of 150
patients, the sensitivity and specificity of CTU for the detection of bladder malignancy was 61.5% and 94.9% using
cystoscopy as the reference standard [21]. However, in another study of 435 patients, CTU performed comparably
to cystoscopy for the detection of bladder malignancy with sensitivity, specificity, positive predictive value (PPV),
and negative predictive value (NPV) of 87%, 99%, 91%, and 98%, compared with 87%, 100%, 98%, and 98%,
respectively, for cystoscopy [22]. The recent DETECT (Detecting Bladder Cancer Using the UroMark Test) 1 study
recommends CTU for gross hematuria because of an upper tract tumor rate of 0.8% [18].
MRU
There is no relevant literature regarding the use of MRU in patients with gross hematuria. Direct comparison of
MRI and CTU sensitivity for evaluation of urothelial lesions in gross hematuria is not available in the literature.
MRI Abdomen and Pelvis
For the purposes of this document, we make a distinction between MRU and MRI abdomen and pelvis without and
with IV contrast. MRI abdomen and pelvis without and with IV contrast is defined as any protocol not specifically
tailored for evaluation of the upper and lower urinary tracts, without both the precontrast and excretory phases, and
without heavily T2-weighted images of the urinary tract.
MRI without contrast may be helpful for the evaluation of gross hematuria. In one study of 130 patients, MRI had
a sensitivity of 98.5% and PPV of 100% for determining the cause of gross hematuria, using cystoscopy and
histopathology as the reference standards [24]. There is no relevant literature regarding the use of MRI with IV
contrast in patients with gross hematuria.
Radiography Abdomen and Pelvis
Conventional radiographs of the abdomen and pelvis (KUB) are not used as a first-line imaging modality for the
evaluation of gross hematuria. There is no relevant literature regarding the use of radiography for the evaluation of
gross hematuria.

ACR Appropriateness Criteria® 7 Hematuria

Radiography Intravenous Urography
IVU is not used as a first-line imaging modality for the evaluation of gross hematuria. There is no relevant literature
regarding the use of IVU for the evaluation of gross hematuria.
US Kidneys and Bladder Retroperitoneal
US, including contrast-enhanced US (CEUS), is not used as first-line imaging modality for the evaluation of gross
hematuria. In a study of 95 patients, US had a sensitivity, specificity, PPV, and NPV of 35.3%, 89.9%, 46.2%, and
84.9%, respectively, when using cystoscopy as the reference standard [25]. In a multicenter trial for the diagnosis
of bladder cancer, US had a sensitivity, specificity, PPV, and NPV of 50.7%, 99.3%, 84.3%, and 96.5%,
respectively, using cystoscopy as the reference standard and, compared with CT, had a sensitivity, specificity, PPV,
and NPV of 80.5%, 97.0%, 79.3%, and 97.2%, respectively [18]. Diagnostic accuracy of US in bladder tumor
detection could be significantly improved by CEUS, which allows the detection of enhancing tumors, as opposed
to nonenhancing hematomas [26]. In 35 patients with cystoscopy and biopsy as the reference standard, CEUS
correctly assessed tumor presence or absence in 88% of cases [27].
Summary of Recommendations
• Variant 1: CT abdomen and pelvis without IV contrast may be appropriate for the initial imaging of
microhematuria in patients with no risk factors or history of recent vigorous exercise, or presence of infection,
viral illness, or present or recent menstruation.
• Variant 2: CTU without and with IV contrast is usually appropriate for the initial imaging of microhematuria
in patients with risk factors, without any of the following: history of recent vigorous exercise, presence of
infection or viral illness, present or recent menstruation, or renal parenchymal disease.
• Variant 3: US kidneys and bladder retroperitoneal is usually appropriate for the initial imaging of
microhematuria in pregnant patients.
• Variant 4: CTU without and with IV contrast or MRU without and with IV contrast is usually appropriate for
the initial imaging of gross hematuria. These procedures are equivalent alternatives (ie, only one procedure will
be ordered to provide the clinical information to effectively manage the patient’s care).
Supporting Documents
The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The
appendix includes the strength of evidence assessment and rating round tabulations for each recommendation.
For additional information on the Appropriateness Criteria methodology and other supporting documents go to
www.acr.org/ac.
Safety Considerations in Pregnant Patients
Imaging of the pregnant patient can be challenging, particularly with respect to minimizing radiation exposure and
risk. For further information and guidance, see the following ACR documents:
• ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging
(MRI) [28]
• ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Adolescents and Women with
Ionizing Radiation [29]
• ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical
Ultrasound [30]
• ACR Manual on Contrast Media [31]
• ACR guidance document on MR safe practices: 2013 [32]

ACR Appropriateness Criteria® 8 Hematuria

Appropriateness Category Names and Definitions
Appropriateness
Appropriateness Category Name Appropriateness Category Definition
Rating
The imaging procedure or treatment is indicated in the
Usually Appropriate 7, 8, or 9 specified clinical scenarios at a favorable risk-benefit
ratio for patients.
The imaging procedure or treatment may be indicated
in the specified clinical scenarios as an alternative to
May Be Appropriate 4, 5, or 6 imaging procedures or treatments with a more
favorable risk-benefit ratio, or the risk-benefit ratio for
patients is equivocal.
The individual ratings are too dispersed from the panel
median. The different label provides transparency
May Be Appropriate regarding the panel’s recommendation. “May be
5
(Disagreement) appropriate” is the rating category and a rating of 5 is
assigned.
The imaging procedure or treatment is unlikely to be
indicated in the specified clinical scenarios, or the
Usually Not Appropriate 1, 2, or 3 risk-benefit ratio for patients is likely to be
unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when
selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with
different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging
examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate
population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at
inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the
long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for
pediatric examinations are lower as compared with those specified for adults (see Table below). Additional
information regarding radiation dose assessment for imaging examinations can be found in the ACR
Appropriateness Criteria® Radiation Dose Assessment Introduction document [33].
Relative Radiation Level Designations
Adult Effective Dose Estimate Pediatric Effective Dose Estimate
Relative Radiation Level*
Range Range
O 0 mSv 0 mSv
☢ <0.1 mSv <0.03 mSv
☢☢ 0.1-1 mSv 0.03-0.3 mSv
☢☢☢ 1-10 mSv 0.3-3 mSv
☢☢☢☢ 10-30 mSv 3-10 mSv
☢☢☢☢☢ 30-100 mSv 10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary
as a function of a number of factors (eg, region of the body exposed to ionizing radiation, the imaging guidance that is used).
The RRLs for these examinations are designated as “Varies.”
References
1. Sharp VJ, Barnes KT, Erickson BA. Assessment of asymptomatic microscopic hematuria in adults. Am Fam
Physician 2013;88:747-54.

ACR Appropriateness Criteria® 9 Hematuria

2. Davis R, Jones JS, Barocas DA, et al. Diagnosis, evaluation and follow-up of asymptomatic microhematuria
(AMH) in adults: AUA guideline. J Urol 2012;188:2473-81.
3. Expert Panel on Pediatric I, Dillman JR, Rigsby CK, et al. ACR Appropriateness Criteria((R)) Hematuria-Child.
J Am Coll Radiol 2018;15:S91-S103.
4. Davis R, Jones JS, Barocas DA, et al. Diagnosis, Evaluation and Follow-up of Asymptomatic Microhematuria
(AMH) in Adults. Available at: https://www.auanet.org/guidelines/asymptomatic-microhematuria-(2012-
reviewed-for-currency-2016).
5. Edwards TJ, Dickinson AJ, Natale S, Gosling J, McGrath JS. A prospective analysis of the diagnostic yield
resulting from the attendance of 4020 patients at a protocol-driven haematuria clinic. BJU Int 2006;97:301-5;
discussion 05.
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The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for
diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in
making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the
selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.
Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document.
The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as
investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged.
The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and
radiologist in light of all the circumstances presented in an individual examination.

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