The photoconductor layer is an important component of direct conversion flat panel X-ray imagers (FPXI); thus, it should be carefully selected to meet the requirements for the X-ray imaging detector, and its properties should be clearly understood to develop the most optimal detector design. Currently, amorphous selenium (a-Se) is the only photoconductor utilized in commercial direct conversion FPXIs for low-energy mammographic imaging, but it is not practically feasible for higher-energy diagnostic imaging. Amorphous lead oxide (a-PbO) photoconductor is considered as a replacement to a-Se in radiography, fluoroscopy, and tomosynthesis applications. In this work, we investigated the X-ray sensitivity of a-PbO, one of the most important parameters for X-ray photoconductors, and examined the underlying mechanisms responsible for charge generation and recombination. The X-ray sensitivity in terms of electron–hole pair creation energy, W±, was measured in a range of electric fields, X-ray energies, and exposure levels. W± decreases with the electric field and X-ray energy, saturating at 18–31 eV/ehp, depending on the energy of X-rays, but increases with the exposure rate. The peculiar dependencies of W± on these parameters lead to a conclusion that, at electric fields relevant to detector operation (~10 V/μm), the columnar recombination and the bulk recombination mechanisms interplay in the a-PbO photoconductor.