Can Primary Care Providers Order CT Urography?
Yes, primary care providers can and should order CT urography when clinically indicated for appropriate urinary tract evaluation, as there are no specialty-specific restrictions on ordering this imaging study.
Clinical Authority and Ordering Capabilities
Primary care physicians have full authority to order CT urography as part of their diagnostic workup for urinary tract conditions. The decision to order this study should be based on clinical indications rather than provider specialty 1.
When Primary Care Should Order CT Urography
High-Risk Hematuria Evaluation
- For patients with high-risk microhematuria (age ≥35 years with ≥3 RBCs/HPF, or any age with risk factors), multiphasic CT urography is the recommended initial imaging study 1
- Risk factors include: smoking history, occupational exposures to chemicals, prior pelvic radiation, cyclophosphamide exposure, chronic indwelling foreign body, or family history of urothelial cancer 1
- CT urography provides comprehensive evaluation of both renal parenchyma and the entire urothelium in a single study 1, 2
Suspected Ureteral Injury in Trauma
- For stable trauma patients with suspected ureteral injuries, IV contrast-enhanced CT with delayed imaging (urogram) should be performed 1
- This applies when there is complex abdominopelvic trauma, pelvic fractures, or penetrating injuries near the ureter 1
Persistent or Recurrent Hematuria
- In patients with persistent or recurrent microhematuria previously evaluated only with renal ultrasound, CT urography may be ordered to evaluate the urothelium 1
When CT Urography is NOT Indicated
Uncomplicated Acute Pyelonephritis
- CT urography is not beneficial for first-time, uncomplicated acute pyelonephritis 1
- Imaging should only be considered if symptoms persist beyond 72 hours of appropriate antibiotic therapy 1
- Nearly 95% of uncomplicated cases become afebrile within 48 hours with proper treatment 1
Low-Risk Microhematuria
- For low-risk patients with microhematuria (age <35 without risk factors), renal ultrasound is the appropriate initial imaging rather than CT urography 1
- This avoids unnecessary radiation exposure and contrast-related complications 1
Technical Considerations for Ordering
Protocol Specifications
When ordering CT urography, specify that the study should include 1:
- Unenhanced (non-contrast) phase for stone detection
- IV contrast-enhanced nephrographic phase
- Delayed excretory phase (at least 5 minutes post-contrast) for urothelial visualization
- Thin-slice acquisition with multiplanar reconstructions
Contraindications to Consider
If CT urography is contraindicated (renal insufficiency, contrast allergy), alternative options include 1:
- MR urography as the preferred alternative
- Retrograde pyelography combined with non-contrast CT or renal ultrasound if both CT and MR urography are contraindicated
Common Pitfalls to Avoid
- Do not order routine CT urography for screening purposes - it should be reserved for specific clinical indications 1
- Do not order CT urography based solely on dipstick hematuria - confirm with microscopic urinalysis showing ≥3 RBCs/HPF before proceeding with imaging workup 1
- Do not delay appropriate referral to urology - while PCPs can order CT urography, patients with gross hematuria or high-risk features should still be referred for cystoscopy and comprehensive urologic evaluation 1
- Avoid ordering "CT abdomen/pelvis with contrast" when CT urography is specifically needed - the protocols differ, and standard CT may miss urothelial lesions without proper excretory phase imaging 1
Coordination with Specialists
While primary care can order CT urography, coordination with urology is essential for 1:
- All patients with gross hematuria (regardless of imaging results)
- High-risk microhematuria patients (who also require cystoscopy)
- Any positive findings on CT urography requiring intervention
- Patients with family history of genetic renal tumor syndromes 1