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Acute Onset of Scrotal Pain-Without Trauma, Without Antecedent Mass

Variant: 1   Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US duplex Doppler scrotum Usually Appropriate O
US scrotum Usually Appropriate O
MRI pelvis (scrotum) without and with IV contrast Usually Not Appropriate O
MRI pelvis (scrotum) without IV contrast Usually Not Appropriate O
CT pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT pelvis without IV contrast Usually Not Appropriate ☢☢☢
Nuclear medicine scan scrotum Usually Not Appropriate ☢☢☢
CT pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢

Panel Members
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition
Discussion of Procedures by Variant
Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging.
Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging.
A. CT Pelvis With IV Contrast
Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging.
B. CT Pelvis Without and With IV Contrast
Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging.
C. CT Pelvis Without IV Contrast
Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging.
D. MRI Pelvis (Scrotum) Without and With IV Contrast
Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging.
E. MRI Pelvis (Scrotum) Without IV Contrast
Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging.
F. Nuclear Medicine Scan Scrotum
Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging.
G. US Duplex Doppler Scrotum
Variant 1: Adult or child. Acute onset of scrotal pain. Without trauma, without antecedent mass. Initial imaging.
H. US Scrotum
Summary of Recommendations
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 the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the 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.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate 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 (e.g., 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. Velasquez J, Boniface MP, Mohseni M. Acute Scrotum Pain: StatPearls Publishing, Treasure Island (FL); 2022.
2. Schick MA, Sternard BT. Testicular Torsion: StatPearls Publishing, Treasure Island (FL); 2022.
3. Bourke MM, Silverberg JZ. Acute Scrotal Emergencies. [Review]. Emergency Medicine Clinics of North America. 37(4):593-610, 2019 Nov.
4. Kyaw L, Choo CSC, Ong LY, Yap TL, Teo HJ, Nah SA. Management of acute testicular pain in children: changing trends with improvements in scrotal ultrasonography over 18 years. Singapore Medical Journal. 64(4):249-254, 2023 04.
5. Pogorelic Z, Mustapic K, Jukic M, et al. Management of acute scrotum in children: a 25-year single center experience on 558 pediatric patients. Can J Urol. 23(6):8594-8601, 2016 Dec.
6. Cassar S, Bhatt S, Paltiel HJ, Dogra VS. Role of spectral Doppler sonography in the evaluation of partial testicular torsion. J Ultrasound Med 2008;27:1629-38.
7. Carter CT, Brown A. Genitourinary Emergencies. In: Stone CK, Humphries RL, eds. CURRENT Diagnosis &amp; Treatment: Emergency Medicine, 8e. New York, NY: McGraw-Hill Education; 2017.
8. Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am 2004;42:349-63.
9. Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. Am Fam Physician 2009;79:583-7.
10. NAMCS/NHAMCS - Ambulatory Health Care Data.  Available at: https://www.cdc.gov/nchs/ahcd/index.htm.
11. Al-Taheini KM, Pike J, Leonard M. Acute epididymitis in children: the role of radiologic studies. Urology 2008;71:826-9; discussion 29.
12. Van Glabeke E, Khairouni A, Larroquet M, Audry G, Gruner M. Acute scrotal pain in children: results of 543 surgical explorations. Pediatr Surg Int 1999;15:353-7.
13. Noske HD, Kraus SW, Altinkilic BM, Weidner W. Historical milestones regarding torsion of the scrotal organs. J Urol 1998;159:13-6.
14. Jefferies MT, Cox AC, Gupta A, Proctor A. The management of acute testicular pain in children and adolescents. [Review]. BMJ. 350:h1563, 2015 Apr 02.
15. Makela E, Lahdes-Vasama T, Rajakorpi H, Wikstrom S. A 19-year review of paediatric patients with acute scrotum. Scand J Surg 2007;96:62-6.
16. Yang C Jr, Song B, Liu X, Wei GH, Lin T, He DW. Acute scrotum in children: an 18-year retrospective study. Pediatric Emergency Care. 27(4):270-4, 2011 Apr.
17. Boettcher M, Bergholz R, Krebs TF, Wenke K, Aronson DC. Clinical predictors of testicular torsion in children. Urology. 79(3):670-4, 2012 Mar.
18. Fujita N, Tambo M, Okegawa T, Higashihara E, Nutahara K. Distinguishing testicular torsion from torsion of the appendix testis by clinical features and signs in patients with acute scrotum. Res Rep Urol 2017;9:169-74.
19. Molokwu CN, Somani BK, Goodman CM. Outcomes of scrotal exploration for acute scrotal pain suspicious of testicular torsion: a consecutive case series of 173 patients. BJU International. 107(6):990-3, 2011 Mar.
20. Lee LK, Monuteaux MC, Hudgins JD, et al. Variation in the evaluation of testicular conditions across United States pediatric emergency departments. American Journal of Emergency Medicine. 36(2):208-212, 2018 Feb.
21. Zhao LC, Lautz TB, Meeks JJ, Maizels M. Pediatric testicular torsion epidemiology using a national database: incidence, risk of orchiectomy and possible measures toward improving the quality of care. Journal of Urology. 186(5):2009-13, 2011 Nov.
22. Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatric Emergency Care. 35(12):821-825, 2019 Dec.
23. Barbosa JABA, de Freitas PFS, Carvalho SAD, et al. Validation of the TWIST score for testicular torsion in adults. International Urology & Nephrology. 53(1):7-11, 2021 Jan.
24. Barbosa JA, Tiseo BC, Barayan GA, et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. Journal of Urology. 189(5):1859-64, 2013 May.
25. Cabo J, Graham K, Chen H, et al. Increasing utilization of the TWIST score in workup of patients with acute scrotal pain: Role in diagnosis and risk stratification. Journal of pediatric urology. 18(6):845.e1-845.e8, 2022 12.
26. Sheth KR, Keays M, Grimsby GM, et al. Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score. Journal of Urology. 195(6):1870-6, 2016 06.
27. Jakobsen JA. Ultrasound contrast agents: clinical applications. Eur Radiol 2001;11:1329-37.
28. Tang C, Fang K, Guo Y, et al. Safety of Sulfur Hexafluoride Microbubbles in Sonography of Abdominal and Superficial Organs: Retrospective Analysis of 30,222 Cases. J Ultrasound Med 2017;36:531-38.
29. Appis AW, Tracy MJ, Feinstein SB. Update on the safety and efficacy of commercial ultrasound contrast agents in cardiac applications. Echo Res Pract 2015;2:R55-62.
30. Piscaglia F, Bolondi L, Italian Society for Ultrasound in M, Biology Study Group on Ultrasound Contrast A. The safety of Sonovue in abdominal applications: retrospective analysis of 23188 investigations. Ultrasound Med Biol 2006;32:1369-75.
31. Tenuta M, Sesti F, Bonaventura I, et al. Use of contrast enhanced ultrasound in testicular diseases: A comprehensive review. [Review]. Andrology. 9(5):1369-1382, 2021 09.
32. Cantisani V, Bertolotto M, Weskott HP, et al. Growing indications for CEUS: The kidney, testis, lymph nodes, thyroid, prostate, and small bowel. [Review]. European Journal of Radiology. 84(9):1675-84, 2015 Sep.
33. Malferrari G, Pulito G, Pizzini AM, et al. MicroV Technology to Improve Transcranial Color Coded Doppler Examinations. J Neuroimaging 2018;28:350-58.
34. Visalli C, Mormina E, Tessitore A, et al. Acute scrotal pain in pediatric patients: diagnosis with an innovative Doppler technique (MicroV). Emerg Radiol 2021;28:209-14.
35. Turna O, Alis D. A comparative study of shear wave elastography in the evaluation of undescended and retractile testes in a pediatric population. J Med Ultrason (2001). 46(2):231-237, 2019 Apr.
36. Xue E, Yu Y, Lin L, Li Z, Su H. Application value of real-time shear wave elastography in differential diagnosis of testicular torsion. Medical Ultrasonography. 22(1):43-48, 2020 03 01.
37. Khatri G, Bhosale PR, Robbins JB, et al. ACR Appropriateness Criteria® Newly Diagnosed Palpable Scrotal Abnormality. J Am Coll Radiol 2022;19:S114-S20.
38. Schieda N, Oto A, Allen BC, et al. ACR Appropriateness Criteria® Staging and Surveillance of Testicular Cancer: 2021 Update. J Am Coll Radiol 2022;19:S194-S207.
39. Tsili AC, Argyropoulou MI, Dolciami M, Ercolani G, Catalano C, Manganaro L. When to ask for an MRI of the scrotum. [Review]. Andrology. 9(5):1395-1409, 2021 09.
40. Tsili AC, Bertolotto M, Turgut AT, et al. MRI of the scrotum: Recommendations of the ESUR Scrotal and Penile Imaging Working Group. [Review]. European Radiology. 28(1):31-43, 2018 Jan.
41. Gotto GT, Chang SD, Nigro MK. MRI in the diagnosis of incomplete testicular torsion. Br J Radiol 2010;83:e105-7.
42. Sanelli PC, Burke BJ, Lee L. Color and spectral doppler sonography of partial torsion of the spermatic cord. AJR Am J Roentgenol 1999;172:49-51.
43. Cramer BM, Schlegel EA, Thueroff JW. MR imaging in the differential diagnosis of scrotal and testicular disease. Radiographics 1991;11:9-21.
44. Mittal PK, Abdalla AS, Chatterjee A, et al. Spectrum of Extratesticular and Testicular Pathologic Conditions at Scrotal MR Imaging. [Review]. Radiographics. 38(3):806-830, 2018 May-Jun.
45. Muglia V, Tucci S, Jr., Elias J, Jr., Trad CS, Bilbey J, Cooperberg PL. Magnetic resonance imaging of scrotal diseases: when it makes the difference. Urology. 2002; 59(3):419-423.
46. Parenti GC, Feletti F, Brandini F, et al. Imaging of the scrotum: role of MRI. Radiol Med (Torino). 114(3):414-24, 2009 Apr.
47. Parenti GC, Feletti F, Carnevale A, Uccelli L, Giganti M. Imaging of the scrotum: beyond sonography. [Review]. Insights Into Imaging. 9(2):137-148, 2018 Apr.
48. Makela E, Lahdes-Vasama T, Ryymin P, et al. Magnetic resonance imaging of acute scrotum. Scand J Surg. 100(3):196-201, 2011.
49. Avery LL, Scheinfeld MH. Imaging of penile and scrotal emergencies. Radiographics. 33(3):721-40, 2013 May.
50. Fernandez-Perez GC, Tardaguila FM, Velasco M, et al. Radiologic findings of segmental testicular infarction. AJR Am J Roentgenol. 2005;184(5):1587-1593.
51. Kim W, Rosen MA, Langer JE, Banner MP, Siegelman ES, Ramchandani P. US MR imaging correlation in pathologic conditions of the scrotum. Radiographics 2007;27:1239-53.
52. Bilagi P, Sriprasad S, Clarke JL, Sellars ME, Muir GH, Sidhu PS. Clinical and ultrasound features of segmental testicular infarction: six-year experience from a single centre. Eur Radiol. 2007;17(11):2810-2818.
53. Sriprasad S, Kooiman GG, Muir GH, Sidhu PS. Acute segmental testicular infarction: differentiation from tumour using high frequency colour Doppler ultrasound. Br J Radiol 2001;74:965-7.
54. Sweet DE, Feldman MK, Remer EM. Imaging of the acute scrotum: keys to a rapid diagnosis of acute scrotal disorders. [Review]. Abdominal Radiology. 45(7):2063-2081, 2020 07.
55. Tsili AC, Bertolotto M, Rocher L, et al. Sonographically indeterminate scrotal masses: how MRI helps in characterization. [Review]. Diagnostic & Interventional Radiology. 24(4):225-236, 2018 Jul.
56. Mathur M, Mills I, Spektor M. Magnetic resonance imaging of the scrotum: pictorial review with ultrasound correlation. [Review]. Abdominal Radiology. 42(7):1929-1955, 2017 07.
57. Parenti GC, Sartoni M, Gaddoni E, Zago S, Campioni P, Mannella P. Imaging of segmental testicular infarction: our experience and literature review. [Review]. Radiologia Medica. 117(7):1161-75, 2012 Oct.
58. Terai A, Yoshimura K, Ichioka K, et al. Dynamic contrast-enhanced subtraction magnetic resonance imaging in diagnostics of testicular torsion. Urology. 2006;67(6):1278-1282.
59. Watanabe Y, Nagayama M, Okumura A, et al. MR imaging of testicular torsion: features of testicular hemorrhagic necrosis and clinical outcomes. J Magn Reson Imaging. 2007;26(1):100-108.
60. Baliyan V, Das CJ, Sharma R, Gupta AK. Diffusion weighted imaging: Technique and applications. World J Radiol 2016;8:785-98.
61. Koh DM, Collins DJ. Diffusion-weighted MRI in the body: applications and challenges in oncology. AJR Am J Roentgenol 2007;188:1622-35.
62. Maki D, Watanabe Y, Nagayama M, et al. Diffusion-weighted magnetic resonance imaging in the detection of testicular torsion: feasibility study. J Magn Reson Imaging. 34(5):1137-42, 2011 Nov.
63. Tokuda B, Kiba M, Yamada K, et al. The split sign: The MRI equivalent of the bell clapper deformity. British Journal of Radiology. 92(1095):20180312, 2019 Mar.
64. Nicola R, Menias CO, Dahiya N, Robinson K, Hara AK, Siegel CL. Review of paratesticular pathology: findings on ultrasound and MRI. [Review]. Abdominal Radiology. 42(2):585-601, 2017 02.
65. Parker RA 3rd, Menias CO, Quazi R, et al. MR Imaging of the Penis and Scrotum. [Review]. Radiographics. 35(4):1033-50, 2015 Jul-Aug.
66. Gupta R, Alobaidi M, Jafri SZ, Bis K, Amendola M. Correlation of US and MRI findings of intratesticular and paratesticular lesions: from infants to adults. Curr Probl Diagn Radiol 2005;34:35-45.
67. O'Malley RB, Al-Hawary MM, Kaza RK, Wasnik AP, Liu PS, Hussain HK. Rectal imaging: part 2, Perianal fistula evaluation on pelvic MRI--what the radiologist needs to know. [Review]. AJR Am J Roentgenol. 199(1):W43-53, 2012 Jul.
68. Amini B, Patel CB, Lewin MR, Kim T, Fisher RE. Diagnostic nuclear medicine in the ED. [Review]. Am J Emerg Med. 29(1):91-101, 2011 Jan.
69. Melloul M, Paz A, Lask D, Manes A, Mukamel E. The value of radionuclide scrotal imaging in the diagnosis of acute testicular torsion. Br J Urol. 1995;76(5):628-631.
70. Hod N, Maizlin Z, Strauss S, Horne T. The relative merits of Doppler sonography in the evaluation of patients with clinically and scintigraphically suspected testicular torsion. Isr Med Assoc J. 2004;6(1):13-15.
71. Lee FT, Jr., Winter DB, Madsen FA, et al. Conventional color Doppler velocity sonography versus color Doppler energy sonography for the diagnosis of acute experimental torsion of the spermatic cord. AJR Am J Roentgenol 1996;167:785-90.
72. Prando D. Torsion of the spermatic cord: the main gray-scale and doppler sonographic signs. Abdom Imaging 2009;34:648-61.
73. Dogra VS, Rubens DJ, Gottlieb RH, Bhatt S. Torsion and beyond: new twists in spectral Doppler evaluation of the scrotum. J Ultrasound Med. 2004;23(8):1077-1085.
74. Gupta A, Dogra V. Role of color flow Doppler ultrasound in the evaluation of acute scrotal pain. [Review]. Andrology. 9(5):1290-1297, 2021 09.
75. Sommers D, Winter T. The scrotum. In: Rumack CM, Levine D, eds. Diagnostic Ultrasound. 5th ed. Philadelphia, PA: Elsevier; 2018:chap 22.
76. Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum. Radiology 2003;227:18-36.
77. Sung EK, Setty BN, Castro-Aragon I. Sonography of the pediatric scrotum: emphasis on the Ts--torsion, trauma, and tumors. [Review]. AJR. American Journal of Roentgenology. 198(5):996-1003, 2012 May.
78. Hamper UM, DeJong MR, Caskey CI, Sheth S. Power Doppler imaging: clinical experience and correlation with color Doppler US and other imaging modalities. Radiographics 1997;17:499-513.
79. Guo X, Sun L, Lei W, Li S, Guo H. Management of testicular torsion <360degree in children: a single-center, retrospective study. Journal of International Medical Research. 48(4):300060519895861, 2020 Apr.
80. Boettcher M, Krebs T, Bergholz R, Wenke K, Aronson D, Reinshagen K. Clinical and sonographic features predict testicular torsion in children: a prospective study. BJU Int. 112(8):1201-6, 2013 Dec.
81. Burks DD, Markey BJ, Burkhard TK, Balsara ZN, Haluszka MM, Canning DA. Suspected testicular torsion and ischemia: evaluation with color Doppler sonography. Radiology 1990;175:815-21.
82. Kalfa N, Veyrac C, Lopez M, et al. Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum. J Urol. 2007;177(1):297-301; discussion 301.
83. Lam WW, Yap TL, Jacobsen AS, Teo HJ. Colour Doppler ultrasonography replacing surgical exploration for acute scrotum: myth or reality? Pediatr Radiol. 2005;35(6):597-600.
84. Altinkilic B, Pilatz A, Weidner W. Detection of normal intratesticular perfusion using color coded duplex sonography obviates need for scrotal exploration in patients with suspected testicular torsion. J Urol. 189(5):1853-8, 2013 May.
85. Baud C, Veyrac C, Couture A, Ferran JL. Spiral twist of the spermatic cord: a reliable sign of testicular torsion. Pediatr Radiol 1998;28:950-4.
86. Bentley DF, Ricchiuti DJ, Nasrallah PF, McMahon DR. Spermatic cord torsion with preserved testis perfusion: initial anatomical observations. J Urol. 2004;172(6 Pt 1):2373-2376.
87. Kalfa N, Veyrac C, Baud C, Couture A, Averous M, Galifer RB. Ultrasonography of the spermatic cord in children with testicular torsion: impact on the surgical strategy. J Urol 2004;172:1692-5; discussion 95.
88. Baker LA, Sigman D, Mathews RI, Benson J, Docimo SG. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics 2000;105:604-7.
89. Vijayaraghavan SB. Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion. J Ultrasound Med. 2006;25(5):563-574.
90. Munden MM, Williams JL, Zhang W, Crowe JE, Munden RF, Cisek LJ. Intermittent testicular torsion in the pediatric patient: sonographic indicators of a difficult diagnosis. AJR Am J Roentgenol. 201(4):912-8, 2013 Oct.
91. Middleton WD, Siegel BA, Melson GL, Yates CK, Andriole GL. Acute scrotal disorders: prospective comparison of color Doppler US and testicular scintigraphy. Radiology 1990;177:177-81.
92. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.
Disclaimer

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.