____________________________________________
A Physicians Survey: Comparing CT versus IVP in the
Diagnosis of Hematuria or Renal Colic
Sameer A. Patel, Kamal N. Morar, Michael G. Edwards
Department of Radiology
Providence Hospital and Medical Center
Southfield, MI 48075
_____________________________________
We conducted a pilot study to examine
physicians’ understanding of the diagnostic
imaging test of choice in regards to patients
presenting with hematuria or renal colic.
Participants were asked to complete a survey
consisting of eight questions regarding this subject
matter.
Nine hundred surveys were circulated at
several community hospitals in a major
metropolitan city and one hundred seventy of them
were returned completed between September and
November 2002. The physicians were then
categorized as Primary Care and Non Primary
Care (Specialist) physicians. The physicians were
also subcategorized as attending physicians and
resident physicians.
Thirty-four out of ninety four (36.2%) primary
care physicians believed that CT scan was a
better diagnostic test than IVP for hematuria.
Forty-two of seventy-six (55.3%) non-primary care
physicians believed that CT scan was a better
diagnostic test than IVP for hematuria. Thirty-
seven out of ninety four (39.4%) primary care
physicians believed that CT scan was the
diagnostic test of choice for renal colic and forty
out of seventy-six (52.6%) non-primary care
physicians believed CT scan was the test of
choice of renal colic.
A significant proportion of physicians in this
pilot study had misconceptions regarding the
diagnostic modality of choice for renal colic and
hematuria. The survey also demonstrated
misconceptions regarding the differences in cost,
radiation exposure, time and level of invasiveness
for CT scan and IVP imaging examinations.
These misconceptions were held by primary care
physicians, specialists, residents and attending
physicians. Increased education in regards to
diagnostic imaging for renal colic and hematuria is
evidently needed in the medical community.
Key Words: CT, IVP, Renal Colic,
Hematuria, Cost, Radiation, Invasive
© 2003 The Journal of Radiology
_____________________________________
Copyright © The Journal of Radiology • www.jradiology.org • January 2003
Urolithiasis is a common condition that
affects a minimum of 12% of the U.S. population
during their lifetime. 1 This medical problem
occurs most frequently in men, usually between the
ages of 20 and 50 years. 2 It accounts for 96 of
100,000 hospital discharges or 122 of 100,000
outpatient visits per year alone here in the United
States. 3 , 4 It often leads to hospitalization 5 and has
recurrence rates reaching 50% in ten years. 6
Patients with urolithiasis typically present
with severe abdominal, back or loin pain. Other
common complaints include nausea, vomiting, flank
pain and hematuria. 7 Rapid diagnosis is essential
in order to exclude other significant conditions that
may present as an acute abdomen and allows for
early implementation of treatment modalities.
Diagnostic imaging plays a crucial role in initiating
this cascade of events and when correctly used, can
lead to decreased cost and improved patient care for
the involved hospital. Good diagnostic tests aids in
clinical decision-making and will improve patient
outcomes by providing guidance for therapeutic
interventions. Conversely, diagnostic tests that
provide no change of patient treatment are of little
value and will not change patient outcomes.
Although intravenous pyelography (IVP) has
been the gold standard for patients presenting with
renal colic in the past, unenhanced computed
tomography (CT) is gaining widespread acceptance
in the medical community. Many studies have
shown unenhanced helical CT to be the study of
choice in the evaluation of patients with suspected
renal colic. 8,9 The benefits of using CT for the
evaluation of renal colic or hematuria include
increased accuracy, decreased procedure time, no
intravenous contrast medium and its associated risk
of reaction and the ability to identify other potential
causes for the patients flank pain. 10 These facts
have been well documented in the literature,
however a recent article published in the American
Journal of Radiology (AJR) by Eisenberg and
Berlin brought to question whether the
medical community was aware of the
literature regarding diagnostic imaging for
renal colic or hematuria. 11
The article involved a urologist,
emergency medicine physician, radiologist
and litigation that was brought up over the
death of a patient with flank pain from the
intravenous contrast medium used during an
IVP. The emergency medicine physician
consulted the urologist who ordered the IVP
despite the radiologist’s recommendation to
use unenhanced CT. This article reveals the
issue that many physicians may not be aware
of the literature regarding this subject and
prompted us to distribute a survey posing
questions regarding the use of CT versus IVP
for patients presenting with renal colic and
hematuria. Questions were also asked
regarding the differences in price, radiation
exposure, length of examination and level of
invasiveness. We hope to gather data
demonstrating whether or not more education
is needed on this subject and about the
benefits and risks of each procedure.
Methods and Materials
Nine hundred surveys were distributed
to various hospitals in a large metropolitan
area. The survey consisted of eight questions
regarding IVP and CT scans for hematuria and
flank pain. (Appendix) There were also
additional questions regarding the differences
in cost, length of exams, level of invasiveness
and dose of radiation from each.
The physicians were first asked to
identify which field of medicine they were in
and whether they were in practice or in
training. The following question asked the
physician were to choose between CT scan
and IVP as an imaging study for a patient with
hematuria. They were asked the same
question regarding renal colic. The following
four questions as previously mentioned then
asked about differences in cost, time required
for examination, radiation and level of
invasiveness.
The question regarding level of invasiveness
of IVP versus CT scans did not include
Copyright © The Journal of Radiology • www.jradiology.org • January 2003
whether the CT scan was with contrast or not. This
allowed us to indirectly examine if the participants
were aware that CT scans for renal colic or
hematuria must be done without contrast in order to
better visualize calculi within the kidneys or
ureteral system.
The question regarding level of radiation exposure
of IVP versus CT scans also did not specify whether
nephrotomograms were part of the IVP.
Nephrotomograms are included routinely when an
IVP is ordered at the institutions we surveyed.
The questionnaires were collected and the data was
compiled as proportions and percentages. The data
was subcategorized according to the type of
physician who completed it and if they were in
training or in practice.
Results
One hundred seventy physicians completed
the survey of nine hundred that were distributed at
multiple hospital centers in a large metropolitan
area over the period of September to November
2002. The results were categorized as specialists
and primary care physicians. The primary care
group was composed of Family Practice physicians
(20/170, 11.8%), Emergency Medicine physicians
(12/170, 7.1%) and Internal Medicine physicians
(62/170, 36.5%). The specialist physicians were
composed of Radiologists (10/170, 5.9%), General
Surgeons (28/170, 16.5%), Obstetricians and
Gynecologists (8/170, 4.7%), Medical sub-
specialists (20/170, 11.8%), and Urologists (10/170,
5.9%).
The primary care physicians totalled 94/170
(55.3%) of the survey participants, of who 34/94
(36.2%) were residents. The specialists totalled
76/170 (44.7%) of the survey participants, of who
12/76 (15.8%) were residents. One hundred percent
of the Radiologists and Medical Specialists were
attending physicians. Fifty percent of the ER
physicians and Family Practitioners were attending
physicians. Seventy one percent of the Internal
Medicine physicians were attending physicians.
Seventy five percent of the OB/GYN physicians
were attending physicians, 78.6% of the General
Surgeons were attending physicians and 60% of the
Urologists were attending physicians.
With regards to hematuria, only 34/94 (36.2
%) primary care physicians and 42/76 (55.3 %) of
specialists believed that CT scan was the diagnostic
test of choice. Seventy-nine out of ninety four
(84%) primary care physicians and 67/76
(88.2%) specialists believed that CT scan was
a more expensive imaging technique than IVP.
Forty-two out of ninety four (44.7%)
primary care physicians and 23/76 (30.3%)
specialists believed that CT scan exposed the
patient to more radiation than IVP.
Eighty-one out of ninety four (86.2%)
primary care physicians and 41/76 (53.9%)
specialists believed that CT scan was more
invasive than IVP when evaluating a patient
for renal colic and hematuria. Three out of
ninety four (3.2%) primary care physicians
and 25/76 (32.9%) specialists believed that CT
scan and IVP were equally invasive.
Eighty out of ninety-four (85.1%)
primary care physicians and 63/76 (82.9%)
specialists believed that CT scan was a
quicker imaging modality than IVP.
Thirty-seven out of ninety four (39.4%)
primary care physicians and 40/76 (52.6%)
specialists believed that CT scan was the test
of choice over IVP for patients presenting
with renal colic.
Discussion
Urolithiasis is a common problem for
millions of people worldwide. This medical
problem accounts for a significant amount of
hospital discharges, outpatient visits and
hospitalization. This problem can recur and
account for repeated visits to inpatient or
outpatient centers. The presentation of
urolithiasis usually includes abdominal, back,
loin or flank pain, and even hematuria. 7
Rapid diagnosis can lead to quicker
therapeutic intervention and exclusion of other
diagnoses that may mimic these symptoms.
The literature clearly demonstrates that
unenhanced CT scan is the new imaging exam
of choice for patients presenting with
symptoms of urolithiasis. A recent
prospective study between IVP and
unenhanced CT demonstrated that CT scan
diagnosed urolithiasis significantly better than
IVP. 10 This study showed that IVP was only
94% specific while spiral CT was 100%
specific. Yet another study by Yilmaz et al.
compared ultrasound, CT and IVP on 97
Copyright © The Journal of Radiology • www.jradiology.org • January 2003
patients with renal colic. Spiral CT yielded the
greatest results with a 94% sensitivity and 97%
specificity compared with IVP, which demonstrated
a 52% sensitivity, and 94% specificity. 12
Numerous other studies have evaluated and
advocate the use of spiral CT for diagnosing acute
flank pain. 13, 14, 15 The increased sensitivity and
specificity of CT scan over IVP for renal colic,
hematuria, and other symptoms of urolithiasis has
been well documented.
Spiral CT also provides detection of other
causes of pain in the groin or abdomen that may not
be related to the kidneys or ureteral system. CT can
easily identify appendicitis, diverticulitis, pelvic
inflammatory disease, ovarian cysts and even
abdominal aortic aneurysm. 16 Another advantage
of spiral CT is the ability to detect radiolucent
calculi and its ability to differentiate between
different compositions of stones. 16, 17 This provides
added information that the IVP cannot. A
significant amount of the physicians in our study
demonstrated a lack of know ledge regarding this
subject. IVP was the study of choice for hematuria
in 63.8% of the primary care physicians surveyed
and 60.6% thought IVP was best for renal colic.
Forty four percent of specialists chose IVP for
hematuria and 47.4% chose IVP for renal colic.
These numbers represent a significant amount of
physicians that may order diagnostic imaging tests
that are no longer considered the “ gold standard”
for symptoms of urolithiasis.
The total cost for hospitalization, evaluation
and treatment of urolithiasis in the United States
alone is estimated to be 1.83 billion dollars. 18 The
difference in cost between the aforementioned
studies has also been well documented in the
literature revealing discrepancies in the data. One
study by Mill and Rineer et al. documented that
non-contrast CT was more expensive than IVP
($256 versus $92 respectively). 10 The article also
documented that the IVP was 240 dollars when
nonionic contrast was used. Similar studies support
this claim that spiral CT is a more expensive
examination than IVP. 19, 20 These studies however
made no mention if nephrotomograms were
included in the cost analysis of the IVP. We found
another study by Rosser and Zagoria that found that
an IVP with four nephrotomograms exposed the
patient to a greater amount of radiation than helical
CT. 21
 This discrepancy in the cost difference
between these studies was also reflected by
the physicians in our survey. Eighty four
percent of primary care physicians and 88.2%
of specialists believed that CT scan was a
more expensive study. The majority of
subjects surveyed believed that CT was the
more expensive study demonstrating that
knowledge regarding use of nephrotomograms
with IVP is also lacking.
When CT scan is ordered as the initial
diagnostic modality for renal injuries, the
number of further tests needed to define the
injury is greatly reduced. 22 This reduction in
repeat radiographic procedures leads to greater
cost-effectiveness and reduction of overall
cost to the treating institution. 10, 22 CT also
improves clinician’s diagnostic confidence
resulting in changes in initial treatment plans,
procedures ordered and decreases in the need
for further imaging and consultation. 23 This
also leads to an overall reduction in health
care cost despite the difference between each
imaging study.
This increase in diagnostic confidence
also results in a reduction of total time spent in
the hospital and decreased admissions. 23
When individually contrasted, CT is proven to
be a faster exam than IVP. 17, 20, 21 IVP often
requires delayed imaging which can increase
the total time of examination. 10 This decrease
in length of examination, cost and overall
reduction in time spent in the hospital only
contributes to the overall cost effectiveness of
CT scan over IVP. Most of the primary care
physicians (85.1%) and specialists (82.9%) we
surveyed correctly believed that CT scan was
a quicker exam than IVP.
One of the greatest benefits of CT scan
over IVP for symptoms of urolithiasis is the
fact that CT scan of the kidneys and ureteral
system do not require intravenous contrast.
IVP requires a contrast medium and carries a
risk of nephrotoxicity and systemic reaction
including urticaria, bronchospasm,
hypotension, anaphylaxis, and death. As
previously mentioned, a lawsuit was brought
against a radiologist regarding the death of a
patient from the IV contrast used during an
IVP ordered for renal colic pain. 11
Shockingly, 86.2% of primary care physicians
Copyright © The Journal of Radiology • www.jradiology.org • January 2003
surveyed and 53.9% of specialists believed that CT
scan was more invasive than IVP when evaluating a
patient for renal colic and hematuria. Interestingly,
3.2% of primary care physicians and 32.9% of
specialists believed that CT scan and IVP were
equally invasive. These results show the lack of
understanding regarding CT scan examination of
the kidneys and ureteral system for symptoms of
urolithiasis.
Our survey aimed to discover if the medical
community was aware of the literature and
indications for unenhanced CT scan for patients
presenting with hematuria and renal colic. The
results we collected demonstrate that a significant
proportion of physicians in this pilot study had
misconceptions regarding the diagnostic modality
of choice for renal colic and hematuria. These
misconceptions also included differences in cost,
radiation exposure, length of exam and level of
invasiveness for CT scan and
IVP. These misunderstandings spanned resident and
attending physicians in all subspecialties of
medicine including Urology, Emergency Medicine
and Radiology. We feel a greater emphasis should
be placed on education regarding the choice of
diagnostic imaging for the various patient
presentations of urolithiasis.
.
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Appendix
Q1. What field of medicine are you in?
Q2. Are you in practice or in training?
Q3. If you consider using IVP or CT scan for hematuria,
which one would you order?
Q4. Which one do you think costs more?
Q5. Which one do you think has higher radiation exposure?
Q6. Which one is less invasive?
Q7. Which one can be performed quicker?
Q8. If you consider using IVP or CT scan for renal colic pain,
which one would you order?