Hematuria-Child

Variant: 1 Child. Isolated microscopic hematuria (nonpainful, nontraumatic) without proteinuria. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Arteriography kidneys	Usually Not Appropriate	☢☢☢☢
US kidneys and bladder	Usually Not Appropriate	O
Voiding urosonography	Usually Not Appropriate	O
Fluoroscopy voiding cystourethrography	Usually Not Appropriate	☢☢
Radiography abdomen and pelvis	Usually Not Appropriate	☢☢☢
Radiography intravenous urography	Usually Not Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	Usually Not 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 IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢

Variant: 2 Child. Isolated microscopic hematuria (nonpainful, nontraumatic) with proteinuria. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US kidneys and bladder	Usually Appropriate	O
Arteriography kidneys	Usually Not Appropriate	☢☢☢☢
Voiding urosonography	Usually Not Appropriate	O
Fluoroscopy voiding cystourethrography	Usually Not Appropriate	☢☢
Radiography abdomen and pelvis	Usually Not Appropriate	☢☢☢
Radiography intravenous urography	Usually Not Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	Usually Not 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 IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢

Variant: 3 Child. Isolated macroscopic hematuria (nonpainful, nontraumatic). Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US kidneys and bladder	Usually Appropriate	O
Arteriography kidneys	Usually Not Appropriate	☢☢☢☢
Voiding urosonography	Usually Not Appropriate	O
Fluoroscopy voiding cystourethrography	Usually Not Appropriate	☢☢
Radiography abdomen and pelvis	Usually Not Appropriate	☢☢☢
Radiography intravenous urography	Usually Not Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	Usually Not 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 IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢

Variant: 4 Child. Painful hematuria (nontraumatic). Suspected urolithiasis. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US kidneys and bladder	Usually Appropriate	O
CT abdomen and pelvis without IV contrast	Usually Appropriate	☢☢☢☢
Radiography abdomen and pelvis	May Be Appropriate	☢☢☢
Arteriography kidneys	Usually Not Appropriate	☢☢☢☢
Voiding urosonography	Usually Not Appropriate	O
Fluoroscopy voiding cystourethrography	Usually Not Appropriate	☢☢
Radiography intravenous urography	Usually Not Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	Usually Not 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 contrast	Usually Not Appropriate	☢☢☢☢☢

Variant: 5 Child. Traumatic hematuria (macroscopic). Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢☢
Fluoroscopy retrograde urethrography	May Be Appropriate	☢☢☢
CT pelvis with bladder contrast (CT cystography)	May Be Appropriate	☢☢☢☢
Arteriography kidneys	Usually Not Appropriate	☢☢☢☢
US kidneys and bladder	Usually Not Appropriate	O
Voiding urosonography	Usually Not Appropriate	O
Fluoroscopy voiding cystourethrography	Usually Not Appropriate	☢☢
Radiography abdomen and pelvis	Usually Not Appropriate	☢☢☢
Radiography intravenous urography	Usually Not Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢

Variant: 6 Child. Traumatic hematuria (microscopic). Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢☢
US kidneys and bladder	May Be Appropriate	O
Fluoroscopy retrograde urethrography	May Be Appropriate	☢☢☢
CT pelvis with bladder contrast (CT cystography)	May Be Appropriate	☢☢☢☢
Arteriography kidneys	Usually Not Appropriate	☢☢☢☢
Voiding urosonography	Usually Not Appropriate	O
Fluoroscopy voiding cystourethrography	Usually Not Appropriate	☢☢
Radiography abdomen and pelvis	Usually Not Appropriate	☢☢☢
Radiography intravenous urography	Usually Not Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢

Panel Members

Jonathan R. Dillman, MD, MSc^a; Cynthia K. Rigsby, MD^b; Ramesh S. Iyer, MD^c; Adina L. Alazraki, MD^d; Sudha A. Anupindi, MD^e; Brandon P. Brown, MD^f; Sherwin S. Chan, MD, PhD^g; Scott R. Dorfman, MD^h; Richard A. Falcone Jr., MD, MPHⁱ; Matthew D. Garber, MD^j; Jie C. Nguyen, MD, MS^k; Craig A. Peters, MD^l; Nabile M. Safdar, MD, MPH^m; Andrew T. Trout, MDⁿ; Boaz Karmazyn, MD^o.

Summary of Literature Review

Introduction/Background

Discussion of Procedures by Variant

Variant 1: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) without proteinuria. Initial imaging.

Variant 1: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) without proteinuria. Initial imaging.
A. CT

Variant 1: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) without proteinuria. Initial imaging.
B. US

Variant 1: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) without proteinuria. Initial imaging.
C. IVU

Variant 1: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) without proteinuria. Initial imaging.
D. MRI

Variant 1: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) without proteinuria. Initial imaging.
E. VCUG

Variant 1: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) without proteinuria. Initial imaging.
F. Voiding Urosonography

Variant 1: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) without proteinuria. Initial imaging.
G. Radiography

Variant 1: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) without proteinuria. Initial imaging.
H. Arteriography

Variant 2: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) with proteinuria. Initial imaging.

Variant 2: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) with proteinuria. Initial imaging.
A. US

Variant 2: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) with proteinuria. Initial imaging.
B. CT

Variant 2: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) with proteinuria. Initial imaging.
C. IVU

Variant 2: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) with proteinuria. Initial imaging.
D. MRI

Variant 2: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) with proteinuria. Initial imaging.
E. Radiography

Variant 2: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) with proteinuria. Initial imaging.
F. VCUG

Variant 2: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) with proteinuria. Initial imaging.
G. Voiding Urosonography

Variant 2: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) with proteinuria. Initial imaging.
H. IVU

Variant 2: Child. Isolated microscopic hematuria (nonpainful, nontraumatic) with proteinuria. Initial imaging.
I. Arteriography

Variant 3: Child. Isolated macroscopic hematuria (nonpainful, nontraumatic). Initial imaging.

Variant 3: Child. Isolated macroscopic hematuria (nonpainful, nontraumatic). Initial imaging.
A. US

Variant 3: Child. Isolated macroscopic hematuria (nonpainful, nontraumatic). Initial imaging.
B. VCUG

Variant 3: Child. Isolated macroscopic hematuria (nonpainful, nontraumatic). Initial imaging.
C. Voiding Urosonography

Variant 3: Child. Isolated macroscopic hematuria (nonpainful, nontraumatic). Initial imaging.
D. CT

Variant 3: Child. Isolated macroscopic hematuria (nonpainful, nontraumatic). Initial imaging.
E. IVU

Variant 3: Child. Isolated macroscopic hematuria (nonpainful, nontraumatic). Initial imaging.
F. MRI

Variant 3: Child. Isolated macroscopic hematuria (nonpainful, nontraumatic). Initial imaging.
G. Arteriography/Venography

Variant 3: Child. Isolated macroscopic hematuria (nonpainful, nontraumatic). Initial imaging.
H. Radiography

Variant 4: Child. Painful hematuria (nontraumatic). Suspected urolithiasis. Initial imaging.

Variant 4: Child. Painful hematuria (nontraumatic). Suspected urolithiasis. Initial imaging.
A. CT

Variant 4: Child. Painful hematuria (nontraumatic). Suspected urolithiasis. Initial imaging.
B. US

Variant 4: Child. Painful hematuria (nontraumatic). Suspected urolithiasis. Initial imaging.
C. Radiography

Variant 4: Child. Painful hematuria (nontraumatic). Suspected urolithiasis. Initial imaging.
D. IVU

Variant 4: Child. Painful hematuria (nontraumatic). Suspected urolithiasis. Initial imaging.
E. MRI

Variant 4: Child. Painful hematuria (nontraumatic). Suspected urolithiasis. Initial imaging.
F. VCUG

Variant 4: Child. Painful hematuria (nontraumatic). Suspected urolithiasis. Initial imaging.
G. Voiding Urosonography

Variant 4: Child. Painful hematuria (nontraumatic). Suspected urolithiasis. Initial imaging.
H. Arteriography

Variant 5: Child. Traumatic hematuria (macroscopic). Initial imaging.

Variant 5: Child. Traumatic hematuria (macroscopic). Initial imaging.
A. CT (including CT cystography)

Variant 5: Child. Traumatic hematuria (macroscopic). Initial imaging.
B. Retrograde Urethrography

Variant 5: Child. Traumatic hematuria (macroscopic). Initial imaging.
C. US

Variant 5: Child. Traumatic hematuria (macroscopic). Initial imaging.
D. IVU

Variant 5: Child. Traumatic hematuria (macroscopic). Initial imaging.
E. Radiography

Variant 5: Child. Traumatic hematuria (macroscopic). Initial imaging.
F. VCUG

Variant 5: Child. Traumatic hematuria (macroscopic). Initial imaging.
G. Voiding Urosonography

Variant 5: Child. Traumatic hematuria (macroscopic). Initial imaging.
H. Arteriography

Variant 5: Child. Traumatic hematuria (macroscopic). Initial imaging.
I. MRI

Variant 6: Child. Traumatic hematuria (microscopic). Initial imaging.

Variant 6: Child. Traumatic hematuria (microscopic). Initial imaging.
A. CT (including CT cystography)

Variant 6: Child. Traumatic hematuria (microscopic). Initial imaging.
B. US

Variant 6: Child. Traumatic hematuria (microscopic). Initial imaging.
C. Arteriography

Variant 6: Child. Traumatic hematuria (microscopic). Initial imaging.
D. Radiography

Variant 6: Child. Traumatic hematuria (microscopic). Initial imaging.
E. VCUG

Variant 6: Child. Traumatic hematuria (microscopic). Initial imaging.
F. Voiding Urosonography

Variant 6: Child. Traumatic hematuria (microscopic). Initial imaging.
G. Retrograde urethrography

Variant 6: Child. Traumatic hematuria (microscopic). Initial imaging.
H. IVU

Variant 6: Child. Traumatic hematuria (microscopic). Initial imaging.
I. MRI

Summary of Highlights

Summary of Evidence

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.	Kaneko K, Tanaka S, Hasui M, et al. A family with X-linked benign familial hematuria. Pediatr Nephrol. 2010; 25(3):545-548.
2.	Kashtan CE. Familial hematuria. Pediatr Nephrol. 2009; 24(10):1951-1958.
3.	Feld LG, Waz WR, Perez LM, Joseph DB. Hematuria. An integrated medical and surgical approach. Pediatr Clin North Am. 1997; 44(5):1191-1210.
4.	Gordon C, Stapleton FB. Hematuria in adolescents. Adolesc Med Clin. 2005; 16(1):229-239.
5.	Patel HP, Bissler JJ. Hematuria in children. Pediatr Clin North Am. 2001; 48(6):1519-1537.
6.	Crop MJ, de Rijke YB, Verhagen PC, Cransberg K, Zietse R. Diagnostic value of urinary dysmorphic erythrocytes in clinical practice. Nephron Clin Pract. 2010; 115(3):c203-212.
7.	Benbassat J, Gergawi M, Offringa M, Drukker A. Symptomless microhaematuria in schoolchildren: causes for variable management strategies. Qjm .1996; 89(11):845-854.
8.	Cilento BG, Jr., Stock JA, Kaplan GW. Hematuria in children. A practical approach. Urol Clin North Am. 1995; 22(1):43-55.
9.	Fitzwater DS, Wyatt RJ. Hematuria. Pediatr Rev. 1994; 15(3):102-108; quiz 109.
10.	Hisano S, Kwano M, Hatae K, et al. Asymptomatic isolated microhaematuria: natural history of 136 children. Pediatr Nephrol. 1991; 5(5):578-581.
11.	Lieu TA, Grasmeder HM, 3rd, Kaplan BS. An approach to the evaluation and treatment of microscopic hematuria. Pediatr Clin North Am. 1991; 38(3):579-592.
12.	Osegbe DN. Haematuria and sickle cell disease. A report of 12 cases and review of the literature. Trop Geogr Med. 1990; 42(1):22-27.
13.	Tarry WF, Duckett JW, Jr., Snyder HM, 3rd. Urological complications of sickle cell disease in a pediatric population. J Urol. 1987; 138(3):592-594.
14.	Meyers KE. Evaluation of hematuria in children. Urol Clin North Am. 2004;31(3):559-573.
15.	Park YH, Choi JY, Chung HS, et al. Hematuria and proteinuria in a mass school urine screening test. Pediatr Nephrol. 2005; 20(8):1126-1130.
16.	Diven SC, Travis LB. A practical primary care approach to hematuria in children. Pediatr Nephrol. 2000;14(1):65-72.
17.	Blumenthal SS, Fritsche C, Lemann J, Jr. Establishing the diagnosis of benign familial hematuria. The importance of examining the urine sediment of family members. JAMA. 1988; 259(15):2263-2266.
18.	Savige J, Rana K, Tonna S, Buzza M, Dagher H, Wang YY. Thin basement membrane nephropathy. Kidney Int. 2003; 64(4):1169-1178.
19.	Bergstein J, Leiser J, Andreoli S. The clinical significance of asymptomatic gross and microscopic hematuria in children. Arch Pediatr Adolesc Med. 2005; 159(4):353-355.
20.	Stapleton FB. Hematuria associated with hypercalciuria and hyperuricosuria: a practical approach. Pediatr Nephrol. 1994; 8(6):756-761.
21.	Jequier S, Cramer B, Petitjeanroget T. Ultrasonographic screening of childhood hematuria. Can Assoc Radiol J. 1987; 38(3):170-176.
22.	Zhai Y, Xu H, Shen Q, et al. Renal histological features of school-age children with asymptomatic haematuria and/or proteinuria: a multicenter study. Nephrology (Carlton). 2014;19(7):426-431.
23.	Kasap B, Soylu A, Turkmen M, Kavukcu S. Relationship of increased renal cortical echogenicity with clinical and laboratory findings in pediatric renal disease. J Clin Ultrasound. 2006;34(7):339-342.
24.	Greenfield SP, Williot P, Kaplan D. Gross hematuria in children: a ten-year review. Urology. 2007; 69(1):166-169.
25.	Shin JI, Park JM, Lee JS, Kim MJ. Effect of renal Doppler ultrasound on the detection of nutcracker syndrome in children with hematuria. Eur J Pediatr. 2007; 166(5):399-404.
26.	Youn T, Trachtman H, Gauthier B. Clinical spectrum of gross hematuria in pediatric patients. Clin Pediatr (Phila). 2006;45(2):135-141.
27.	Gleason PE, Kramer SA. Genitourinary polyps in children. Urology. 1994; 44(1):106-109.
28.	Lee CC, Lin JT, Deng HH, Lin ST. Hematuria due to nutcracker phenomenon of left renal vein: report of a case. J Formos Med Assoc. 1993; 92(3):291-293.
29.	Takahashi Y, Akaishi K, Sano A, Kuroda Y. Intra-arterial digital subtraction angiography for children with idiopathic renal bleeding: a diagnosis of nutcracker phenomenon. Clin Nephrol. 1988; 30(3):134-140.
30.	Lerena J, Krauel L, Garcia-Aparicio L, Vallasciani S, Sunol M, Rodo J. Transitional cell carcinoma of the bladder in children and adolescents: six-case series and review of the literature. J Pediatr Urol. 2010; 6(5):481-485.
31.	Ander H, Donmez MI, Yitgin Y, et al. Urothelial carcinoma of the urinary bladder in pediatric patients: a long-term follow-up. Int Urol Nephrol. 2015;47(5):771-774.
32.	Vianello FA, Mazzoni MB, Peeters GG, et al. Micro- and macroscopic hematuria caused by renal vein entrapment: systematic review of the literature. Pediatr Nephrol. 2016;31(2):175-184.
33.	Fu WJ, Hong BF, Gao JP, et al. Nutcracker phenomenon: a new diagnostic method of multislice computed tomography angiography. Int J Urol. 2006; 13(7):870-873.
34.	Mishra VC, Rowe E, Rao AR, et al. Role of i.v. urography in patients with haematuria. Scand J Urol Nephrol. 2004; 38(3):236-239.
35.	Fitoz S, Ekim M, Ozcakar ZB, Elhan AH, Yalcinkaya F. Nutcracker syndrome in children: the role of upright position examination and superior mesenteric artery angle measurement in the diagnosis. J Ultrasound Med. 2007; 26(5):573-580.
36.	Hogg RJ, Silva FG, Berry PL, Wenz JE. Glomerular lesions in adolescents with gross hematuria or the nephrotic syndrome. Report of the Southwest Pediatric Nephrology Study Group. Pediatr Nephrol. 1993; 7(1):27-31.
37.	Shin JI, Park JM, Lee JS, Kim MJ. Doppler ultrasonographic indices in diagnosing nutcracker syndrome in children. Pediatr Nephrol. 2007; 22(3):409-413.
38.	Shin JI, Park JM, Lee SM, et al. Factors affecting spontaneous resolution of hematuria in childhood nutcracker syndrome. Pediatr Nephrol. 2005; 20(5):609-613.
39.	Alarcon CM, Cubillana PL, Aleman AC, Avellaneda EC. Hematuria secondary to congenital arteriovenous fistula treated with embolization. Arch Esp Urol. 2011; 64(6):550-553.
40.	Ashley RA, Figueroa TE. Gross hematuria in a 3-year-old girl caused by a large isolated bladder hemangioma. Urology. 2010; 76(4):952-954.
41.	Ben Abdallah Chabchoub R, Chabchoub K, Maaloul I, et al. [Nutcracker syndrome: a rare cause of hematuria]. Arch Pediatr. 2011; 18(11):1188-1190.
42.	Polito C, La Manna A, Signoriello G, Marte A. Recurrent abdominal pain in childhood urolithiasis. Pediatrics. 2009; 124(6):e1088-1094.
43.	Persaud AC, Stevenson MD, McMahon DR, Christopher NC. Pediatric urolithiasis: clinical predictors in the emergency department. Pediatrics. 2009; 124(3):888-894.
44.	Strouse PJ, Bates DG, Bloom DA, Goodsitt MM. Non-contrast thin-section helical CT of urinary tract calculi in children. Pediatr Radiol. 2002; 32(5):326-332.
45.	Alpay H, Ozen A, Gokce I, Biyikli N. Clinical and metabolic features of urolithiasis and microlithiasis in children. Pediatr Nephrol. 2009; 24(11):2203-2209.
46.	Cochat P, Pichault V, Bacchetta J, et al. Nephrolithiasis related to inborn metabolic diseases. Pediatr Nephrol. 2010; 25(3):415-424.
47.	Levine JA, Neitlich J, Verga M, Dalrymple N, Smith RC. Ureteral calculi in patients with flank pain: correlation of plain radiography with unenhanced helical CT. Radiology 1997; 204(1):27-31.
48.	Oner S, Oto A, Tekgul S, et al. Comparison of spiral CT and US in the evaluation of pediatric urolithiasis. Jbr-Btr. 2004; 87(5):219-223.
49.	Palmer JS, Donaher ER, O'Riordan MA, Dell KM. Diagnosis of pediatric urolithiasis: role of ultrasound and computerized tomography. J Urol. 2005; 174(4 Pt 1):1413-1416.
50.	O'Connor OJ, McSweeney SE, Maher MM. Imaging of hematuria. Radiol Clin North Am. 2008; 46(1):113-132, vii.
51.	Potretzke AM, Monga M. Imaging modalities for urolithiasis: impact on management. Curr Opin Urol. 2008; 18(2):199-204.
52.	Fielding JR, Steele G, Fox LA, Heller H, Loughlin KR. Spiral computerized tomography in the evaluation of acute flank pain: a replacement for excretory urography. J Urol. 1997;157(6):2071-2073.
53.	Niemann T, Kollmann T, Bongartz G. Diagnostic performance of low-dose CT for the detection of urolithiasis: a meta-analysis. AJR Am J Roentgenol. 2008;191(2):396-401.
54.	Poletti PA, Platon A, Rutschmann OT, Schmidlin FR, Iselin CE, Becker CD. Low-dose versus standard-dose CT protocol in patients with clinically suspected renal colic. AJR Am J Roentgenol. 2007;188(4):927-933.
55.	Smith RC, Verga M, McCarthy S, Rosenfield AT. Diagnosis of acute flank pain: value of unenhanced helical CT. AJR Am J Roentgenol. 1996;166(1):97-101.
56.	Karmazyn B, Frush DP, Applegate KE, Maxfield C, Cohen MD, Jones RP. CT with a computer-simulated dose reduction technique for detection of pediatric nephroureterolithiasis: comparison of standard and reduced radiation doses. AJR. 2009; 192(1):143-149.
57.	Kulkarni NM, Uppot RN, Eisner BH, Sahani DV. Radiation Dose Reduction at Multidetector CT with Adaptive Statistical Iterative Reconstruction for Evaluation of Urolithiasis: How Low Can We Go? Radiology. 2012; 265(1):158-166.
58.	Dunmire B, Harper JD, Cunitz BW, et al. Use of the Acoustic Shadow Width to Determine Kidney Stone Size with Ultrasound. J Urol. 195(1):171-7, 2016 Jan.
59.	Lee JY, Kim SH, Cho JY, Han D. Color and power Doppler twinkling artifacts from urinary stones: clinical observations and phantom studies. AJR. 2001; 176(6):1441-1445.
60.	Turrin A, Minola P, Costa F, Cerati L, Andrulli S, Trinchieri A. Diagnostic value of colour Doppler twinkling artefact in sites negative for stones on B mode renal sonography. Urol Res. 2007; 35(6):313-317.
61.	Shabana W, Bude RO, Rubin JM. Comparison between color Doppler twinkling artifact and acoustic shadowing for renal calculus detection: an in vitro study. Ultrasound Med Biol. 2009; 35(2):339-350.
62.	Dillman JR, Kappil M, Weadock WJ, et al. Sonographic twinkling artifact for renal calculus detection: correlation with CT. Radiology. 2011; 259(3):911-916.
63.	Masch WR, Cohan RH, Ellis JH, Dillman JR, Rubin JM, Davenport MS. Clinical Effectiveness of Prospectively Reported Sonographic Twinkling Artifact for the Diagnosis of Renal Calculus in Patients Without Known Urolithiasis. AJR Am J Roentgenol. 206(2):326-31, 2016 Feb.
64.	Johnson EK, Faerber GJ, Roberts WW, et al. Are stone protocol computed tomography scans mandatory for children with suspected urinary calculi? Urology. 2011; 78(3):662-666.
65.	McAleer IM, Kaplan GW. Pediatric genitourinary trauma. Urol Clin North Am. 1995; 22(1):177-188.
66.	Stalker HP, Kaufman RA, Stedje K. The significance of hematuria in children after blunt abdominal trauma. AJR. 1990; 154(3):569-571.
67.	Brown SL, Haas C, Dinchman KH, Elder JS, Spirnak JP. Radiologic evaluation of pediatric blunt renal trauma in patients with microscopic hematuria. World J Surg. 2001; 25(12):1557-1560.
68.	Chopra P, St-Vil D, Yazbeck S. Blunt renal trauma-blessing in disguise? J Pediatr Surg. 2002; 37(5):779-782.
69.	Levy JB, Baskin LS, Ewalt DH, et al. Nonoperative management of blunt pediatric major renal trauma. Urology. 1993; 42(4):418-424.
70.	Morey AF, Bruce JE, McAninch JW. Efficacy of radiographic imaging in pediatric blunt renal trauma. J Urol. 1996; 156(6):2014-2018.
71.	Nguyen MM, Das S. Pediatric renal trauma. Urology. 2002; 59(5):762-766; discussion 766-767.
72.	Santucci RA, Langenburg SE, Zachareas MJ. Traumatic hematuria in children can be evaluated as in adults. J Urol. 2004; 171(2 Pt 1):822-825.
73.	Nance ML, Lutz N, Carr MC, Canning DA, Stafford PW. Blunt renal injuries in children can be managed nonoperatively: outcome in a consecutive series of patients. J Trauma. 2004; 57(3):474-478; discussion 478.
74.	Taylor GA, Eichelberger MR, Potter BM. Hematuria. A marker of abdominal injury in children after blunt trauma. Ann Surg. 1988; 208(6):688-693.
75.	Perez-Brayfield MR, Gatti JM, Smith EA, et al. Blunt traumatic hematuria in children. Is a simplified algorithm justified? J Urol. 2002; 167(6):2543-2546; discussion 2546-2547.
76.	Abou-Jaoude WA, Sugarman JM, Fallat ME, Casale AJ. Indicators of genitourinary tract injury or anomaly in cases of pediatric blunt trauma. J Pediatr Surg. 1996; 31(1):86-89; discussion 90.
77.	Thorp AW, Young TP, Brown L. Test characteristics of urinalysis to predict urologic injury in children. West J Emerg Med. 2011;12(2):168-172.
78.	Rathaus V, Pomeranz A, Shapiro-Feinberg M, Zissin R. Isolated severe renal injuries after minimal blunt trauma to the upper abdomen and flank: CT findings. Emerg Radiol. 2004; 10(4):190-192.
79.	Raz O, Haifler M, Copel L, et al. Use of adult criteria for slice imaging may limit unnecessary radiation exposure in children presenting with hematuria and blunt abdominal trauma. Urology. 2011; 77(1):187-190.
80.	Smith JK, Kenney PJ. Imaging of renal trauma. [Review] [58 refs]. Radiol Clin North Am. 41(5):1019-35, 2003 Sep.
81.	Morgan DE, Nallamala LK, Kenney PJ, Mayo MS, Rue LW, 3rd. CT cystography: radiographic and clinical predictors of bladder rupture. AJR. 2000; 174(1):89-95.
82.	Peng MY, Parisky YR, Cornwell EE, 3rd, Radin R, Bragin S. CT cystography versus conventional cystography in evaluation of bladder injury. AJR. 1999; 173(5):1269-1272.
83.	Sivit CJ, Cutting JP, Eichelberger MR. CT diagnosis and localization of rupture of the bladder in children with blunt abdominal trauma: significance of contrast material extravasation in the pelvis. AJR. 1995; 164(5):1243-1246.
84.	Chan DP, Abujudeh HH, Cushing GL, Novelline RA. CT cystography with multiplanar reformation for suspected bladder rupture: experience in 234 cases. AJR Am J Roentgenol. 2006 Nov;187(5):1296-302.
85.	Filiatrault D, Longpre D, Patriquin H, et al. Investigation of childhood blunt abdominal trauma: a practical approach using ultrasound as the initial diagnostic modality. Pediatr Radiol. 1987; 17(5):373-379.
86.	Korner M, Krotz MM, Degenhart C, Pfeifer KJ, Reiser MF, Linsenmaier U. Current Role of Emergency US in Patients with Major Trauma. Radiographics. 2008; 28(1):225-242.
87.	Sirlin CB, Brown MA, Deutsch R, et al. Screening US for blunt abdominal trauma: objective predictors of false-negative findings and missed injuries. Radiology. 2003; 229(3):766-774.
88.	Mayor B, Gudinchet F, Wicky S, Reinberg O, Schnyder P. Imaging evaluation of blunt renal trauma in children: diagnostic accuracy of intravenous pyelography and ultrasonography. Pediatr Radiol. 1995;25(3):214-218.
89.	McGahan JP, Horton S, Gerscovich EO, et al. Appearance of solid organ injury with contrast-enhanced sonography in blunt abdominal trauma: preliminary experience. AJR Am J Roentgenol. 187(3):658-66, 2006 Sep.
90.	Valentino M, Serra C, Pavlica P, et al. Blunt abdominal trauma: diagnostic performance of contrast-enhanced US in children--initial experience. Radiology. 2008; 246(3):903-909.
91.	Halachmi S, Chait P, Hodapp J, et al. Renal pseudoaneurysm after blunt renal trauma in a pediatric patient: management by angiographic embolization. Urology. 2003;61(1):224.
92.	Saad DF, Gow KW, Redd D, Rausbaum G, Wulkan ML. Renal artery pseudoaneurysm secondary to blunt trauma treated with microcoil embolization. J Pediatr Surg. 2005;40(11):e65-67.
93.	Wu SR, Shakibai S, McGahan JP, Richards JR. Combined head and abdominal computed tomography for blunt trauma: which patients with minor head trauma benefit most? Emerg Radiol. 2006; 13(2):61-67.
94.	Olthof DC, Joosse P, van der Vlies CH, de Reijke TM, Goslings JC. Routine urinalysis in patients with a blunt abdominal trauma mechanism is not valuable to detect urogenital injury. Emergency Medicine Journal. 32(2):119-23, 2015 Feb.
95.	Holmes JF, Mao A, Awasthi S, McGahan JP, Wisner DH, Kuppermann N. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med. 2009; 54(4):528-533.
96.	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.