When to Refer for Pyelography in Patients with Urinary Tract Symptoms and Kidney Disease
Pyelography (retrograde pyelography) should be reserved for high-risk patients with microhematuria or urinary tract symptoms when both CT urography and MR urography are contraindicated, and it must be combined with non-contrast axial imaging or renal ultrasound. 1
Primary Indications for Pyelography
High-Risk Microhematuria Patients
- Retrograde pyelography is indicated only when multiphasic CT urography and MR urography are both contraindicated (e.g., chronic kidney disease with contrast allergy or severe renal impairment). 1
- This represents a third-line imaging option specifically for evaluating the urothelium when cross-sectional imaging cannot be performed. 1
- Must be combined with either non-contrast CT or renal ultrasound to assess the renal parenchyma. 1
Contraindications to Preferred Imaging
The decision tree follows this hierarchy: 1
- First choice: Multiphasic CT urography (if no contraindications)
- Second choice: MR urography (if CT contraindicated)
- Third choice: Retrograde pyelography + non-contrast imaging (if both CT and MR contraindicated)
When Pyelography is NOT Indicated
Acute Pyelonephritis
- Pyelography has no role in acute pyelonephritis evaluation. 2, 3
- Imaging is not routinely required for uncomplicated pyelonephritis, as 95% of patients become afebrile within 48 hours of appropriate antibiotics. 2
- When imaging is needed (failure to respond after 72 hours), contrast-enhanced CT is the study of choice, not pyelography. 2, 4
Chronic Kidney Disease Monitoring
- Pyelography is not part of routine CKD surveillance. 1
- Upper tract imaging in CKD patients should utilize ultrasound or non-contrast CT to avoid contrast-related complications. 1
- Referral to nephrology is indicated for persistent proteinuria >1 g/day (ACR ≥60 mg/mmol), abrupt sustained eGFR decrease >20%, or unexplained GFR changes. 1
Lower Urinary Tract Symptoms
- Pyelography is not indicated for routine evaluation of LUTS in older men. 1
- Upper urinary tract imaging (when needed) should be ultrasound or excretory urography, reserved for specific indications: upper UTI history, hematuria, urolithiasis history, renal insufficiency, or recent onset nocturnal enuresis. 1
Specific Clinical Scenarios Requiring Nephrology/Urology Referral (Without Pyelography)
Urgent Referral Indications
- Abrupt sustained eGFR decrease >20% after excluding reversible causes. 1
- Persistent proteinuria >1 g/day (ACR ≥60 mg/mmol or PCR ≥100 mg/mmol) where renal biopsy may be indicated. 1
- Recurrent nephrolithiasis requiring specialized evaluation. 1
- Suspected polycystic kidney disease or hereditary nephritis. 1
High-Risk Microhematuria Features Requiring Specialist Referral
Refer to urology when patients have: 1
- Irritative lower urinary tract symptoms
- Prior pelvic radiation or cyclophosphamide/ifosfamide chemotherapy
- Family history of urothelial cancer or Lynch Syndrome
- Occupational exposures to benzene chemicals or aromatic amines
- Chronic indwelling foreign body in urinary tract
Common Pitfalls to Avoid
- Do not order pyelography as a first-line test for any urinary tract evaluation—it is exclusively a third-line option when modern cross-sectional imaging is contraindicated. 1
- Do not confuse retrograde pyelography with intravenous pyelography (IVP)—IVP is largely obsolete and has been replaced by CT urography for most indications. 5, 6
- Do not delay nephrology referral in patients with progressive CKD (eGFR <30 mL/min/1.73 m²) or high risk of ESRD (10-20% risk within 1 year) while pursuing imaging studies. 1
- Do not order imaging for uncomplicated pyelonephritis unless the patient fails to respond within 72 hours—premature imaging adds no clinical value. 2, 3
- Recognize that in patients with kidney disease and contrast contraindications, the combination of non-contrast CT or ultrasound plus retrograde pyelography provides adequate urothelial evaluation without the risks of iodinated or gadolinium-based contrast. 1