Direct Access Non-Obstetric Ultrasound (NOUS) - Referral Guidance

  • Bladder
  • General abdomen
  • Gynaecology (including transvaginal)
  • Musculoskeletal
  • Prostate
  • Renal
  • Scrotal
  • Testicular

  • Cancer - any patient with suspected cancer which meets the 2ww criteria should be referred by 2ww pathway (unless scan is requested by Radiologist following a suspicious plain film).
  • Children under 18 years of age.
  • Patients needing general anaesthetic, hospital inpatients and non-NHS patients.
  • Note: BMI restrictions dependent on weight limits of couch (please check with provider for thresholds).
  • Note: body parts not stated in the inclusions list are expressly excluded from this service provision.

If you have any queries or need clinical advice as to the appropriateness of the request, please contact the chosen provider for information. The provider is at liberty to refuse a request or phone the clinician for further details if they feel the imaging is inappropriate.

When considering ordering imaging, please consider the following:

  • The Royal College of Radiologists iRefer Guidelines should be used to support decisions around clinical appropriateness - see National and NICE Guidance.
  • You will need to explain the findings to the patient, so be clear that the investigation is indicated and you know what to do with the result
  • Be aware that scans show incidental findings in a number of cases that can then lead to further possibly unnecessary imaging and associated financial cost and anxieties.

The brief information below is a guide and does not replace the full advice, diagnosis and management that an outpatient referral can give. Please refer to the RCR iRefer Guidelines for further information.

  • Includes assessment of the aorta, biliary tract, gallbladder, inferior vena cava, kidneys, liver, pancreas, retroperitoneum and spleen.

Please also see iRefer Guidelines.

USS pelvis for gynaecological conditions is indicated for:

  • Palpable uterus per abdomen with pressure symptoms
  • Palpable uterus per abdomen with menorrhagia, abnormal uterine bleeding
  • 45 plus women with normal endometrial biopsy after failed first line medical treatment
  • Failed medical treatment for menstrual problems any age
  • Pelvic pain when examination suggestive of ovarian cysts
  • Pelvic pain in women with raised BMI where vaginal examination not helpful
  • Cyclical pain in women who are oligomenorrhoeic post endometrial ablation to rule out haematometra
  • Palpable adnexal or pouch of Douglas/pelvic mass in women with pelvic pain
  • Missing coil threads
  • TVS pelvis for PMB for endometrial thickness outside 2 week criteria (which is single heavy bleed or multiple small PV bleeds in women over age of 55, not on HRT
  • Oligomenorrhoeic/secondary amenorrhaoea patients to check for polycystic ovaries
  • TVS pelvis to rule out uterine abnormalities in women with recurrent miscarriage
  • TVS is often more sensitive for small ovarian pathology or endometrial thickness; please consider this in your request.

Please also see iRefer Guidelines.

Chest and Cardiovascular - iRefer Non-obstetric Ultrasound (NOUS) Diagnostic Guidance

Scan indicated: NOUS Abdomen
Additional Information: US is useful in diagnosis, determination of maximal diameter, screening and surveillance.
Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section
Gastrointestinal - iRefer Non-obstetric Ultrasound (NOUS) Diagnostic Guidance

Scan indicated: NOUS Abdomen
Additional Information: US reliably differentiates between obstructive and non-obstructive jaundice, but bile duct dilatation may be subtle in early obstruction. When US indicates obstructive jaundice, subsequent investigation will depend on the level of obstruction, presence or absence of stones in the gall bladder and ducts, as well as the clinical situation. Early discussion with a radiologist is required or referral to speciality consultant / admission 
Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: NOUS Abdomen
Additional Information: US is sensitive for ascites and portal vein patency. In portal hypertension US may show varices, especially in the splenic hilum. US is of lower sensitivity than CT or MRI for the detection and confirmation of hepatoma.  
Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: 1. NOUS Abdomen
2. CT Abdomen
3. MRI Abdomen
Additional Information: US often solves the problem.  CT is used when US is inconclusive, and to provide more complete assessment of disease extent before definitive treatment.  If definite Neoplasm proceed to CT.  MRI may be helpful for distinguishing malignancy when ultrasound and CT are equivocal.
Other images or tests that should be done prior to undertaking this: NOUS before CTCT before MRI
How to access scan indicated: Please see Services and Referrals section

Scan indicated: NOUS Abdomen
Additional Information: US shows pancreatic parenchymal changes and calcification. 
Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: NOUS Abdomen
Additional Information: US is the investigation of choice to show or to exclude gallstones and acute cholecystitis. It is the initial investigation of biliary pain but cannot reliably exclude common duct stones.
Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section
Gynaecology - iRefer Non-obstetric Ultrasound (NOUS) Diagnostic Guidance

Scan indicated: NOUS Pelvis
Additional Information: Most IUCDs are echogenic and can be identified on transabdominal US. Their correct placement is best ascertained with TVUS. Mirena IUD (levonorgesterel device) is plastic and less echogenic and TVUS will be required for assessment in this situation. 
Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: NOUS Pelvis
Additional Information: US (including transvaginal and transrectal US) is helpful, especially when clinical examination is difficult or impossible.  Not helpful in diagnosing PID which is a clinical / microbiological diagnosis.  In the clinical setting laparoscopy is usually the next step after US. 
Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: NOUS Pelvis
Additional Information: TVUS is indicated to exclude significant endometrial pathology in post-menopausal bleeding. Endometrial thickening ≥ 5mm or abnormal endometiral morphology or non-visualisation requires biopsy. Recurrent postmenopausal bleeding will require histological diagnosis irrespective of US findings.
Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: NOUS Pelvis
Additional Information: A combination of transabdominal and TVUS is often required. US should confirm a lesion's presence and determine the likely organ of origin. TVUS should be used to define the anatomy further.
Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: NOUS Pelvis
Additional Information:

Polycystic ovary syndrome is a clinical and biochemical diagnosis. At least 2 of these criteria are required:

  • Oligomenorrhoea and/or anovulation
  • Clinical and/or biochemical hyperandrogenism with measurement of the Free Androgen Index
  • Polycystic ovaries, with the exclusion of other causes.

The diagnosis os a polycystic ovary on US requires the demonstration of at least 12 follicles measuring 2-9mm in diameter and/or an ovarian volume in excess of 10ml.

Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section
Musculoskeletal - iRefer Non-obstetric Ultrasound (NOUS) Diagnostic Guidance

Scan indicated: NOUS
Additional Information:

US is useful as the first investigation to evaluate cystic and solid masses, and to distinguish them from pseudotumours. It is also useful to monitor benign masses (e.g. haematomas) and to assess for local recurrence of soft tissue sarcomas.

Local soft tissue ultrasound pathway to follow

Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section
Urogenital and Adrenal - iRefer Non-obstetric Ultrasound (NOUS) Diagnostic Guidance

Scan indicated: NOUS Urinary Tract
Additional Information:

Bladder US (with measurement of post-void residual volume and urine flow rate) is helpful in LUTS. Renal US to check for upper tract dilatation only if there is a post-void residue.

Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: NOUS Urinary Tract
Additional Information:

US also indicated for renal insufficiency, haematuria, stones or infection.

Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: NOUS Urinary Tract
Additional Information:

US is indicated as the first investigation in renal failure to measure kidney size and parenchymal thickness and to check for pelvicalyceal dilatation indicating possible obstruction. US may also be used to guide renal biopsy when histological diagnosis is required.

Additional comments: 
Suspected pre-renal failure requires US alone. Renal causes are best investigated with US, then possibly NM and US-guided biopsy. Post-renal/obstructive causes require CT/MRI, in addition to US.

Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: NOUS Urinary Tract
Additional Information:

US is sensitive at detecting renal masses >2 cm and accurately distinguishes cystic or solid masses and helps to characterise some masses indeterminate at CT. Contrast-enhanced ultrasound can be useful for further characterisation of small solid or cystic renal masses.

Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: NOUS Scrotum
Additional Information:

US with colour Doppler is indicated for testicular or scrotal swelling or when presumed inflammatory pain does not resolve. A painless testicular swelling requires urgent investigation. US allows differentiation of testicular from extra-testicular lesions.

Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: NOUS Urinary Tract
Additional Information:

US can be used to assess the degree of collecting system dilatation (not always due to obstruction), the Doppler spectral pattern of intrarenal blood flow, the bladder, and the presence of ureteric jets.

Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section
Direct Access Ultrasound Referral Pathway

     

 

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