OBJECTIVE: To assess the reproducibility and impact of prostate imaging quality (PI-QUAL) scores in a clinical cohort undergoing prostate multiparametric MRI. METHODS: PI-QUAL scores were independently recorded by three radiologists (two senior, one junior). Readers also recorded whether MRI was sufficient to rule-in/out cancer and if repeat imaging was required. Inter-reader agreement was assessed using Cohen's κ. PI-QUAL scores were further correlated to PI-RADS score, number of biopsy procedures, and need for repeat imaging. RESULTS: Image quality was sufficient (≥PI-QUAL-3) in 237/247 (96%) and optimal (≥PI-QUAL-4) in 206/247 (83%) of males undergoing 3T-MRI. Overall PI-QUAL scores showed moderate inter-reader agreement for senior (K = 0.51) and junior-senior readers (K = 0.47), with DCE showing highest agreement (K = 0.47). With PI-QUAL-5 studies, the negative MRI calls increased from 50 to 87% and indeterminate PI-RADS-3 rates decreased from 31.8. to 10.4% compared to lower quality PI-QUAL-3 studies. More patients with PI-QUAL scores 1-3 underwent biopsy for negative (47%) and indeterminate probability (100%) MRIs compared to PI-QUAL score 4-5 (30 and 75%, respectively). Ability to rule-in cancer increased with PI-QUAL score, from 50% at PI-QUAL 1-2 to 90% for PI-QUAL 4-5, with a similarly, but greater effect for ruling-out cancer and at a lower threshold, from 0% for scans of PI-QUAL 1-2 to 67.1% for PI-QUAL 4 and 100% for PI-QUAL-5. CONCLUSION: Higher PI-QUAL scores for image quality are associated with decreased uncertainty in MRI decision-making and improved efficiency of diagnostic pathway delivery. ADVANCES IN KNOWLEDGE: This study demonstrates moderate inter-reader agreement for PI-QUAL scoring and validates the score in a clinical setting, showing correlation of image quality to certainty of decision making and clinical outcomes of repeat imaging and biopsy of low-to-intermediate risk cases.