Penetrating Trauma-Abdomen and Pelvis

Variant: 1 Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
CTU without and with IV contrast	Usually Appropriate	☢☢☢☢
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	May Be Appropriate	☢☢☢☢
US kidneys and bladder retroperitoneal	Usually Not Appropriate	O
Radiography intravenous urography	Usually Not Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRI abdomen without and with IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast	Usually Not Appropriate	O
MRU without and with IV contrast	Usually Not Appropriate	O
MRU without IV contrast	Usually Not Appropriate	O

Variant: 2 Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Fluoroscopy retrograde urethrography	Usually Appropriate	☢☢☢
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
CT pelvis with bladder contrast (CT cystography)	Usually Appropriate	☢☢☢☢
Fluoroscopy voiding cystourethrography	May Be Appropriate (Disagreement)	☢☢
Fluoroscopy retrograde cystography	May Be Appropriate (Disagreement)	☢☢☢
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
CT pelvis with IV contrast	May Be Appropriate	☢☢☢
CT pelvis without IV contrast	May Be Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	May Be Appropriate (Disagreement)	☢☢☢☢
CT pelvis without and with IV contrast	May Be Appropriate	☢☢☢☢
CTU without and with IV contrast	May Be Appropriate (Disagreement)	☢☢☢☢
US pelvis (bladder and urethra)	Usually Not Appropriate	O
Radiography intravenous urography	Usually Not Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRI pelvis without and with IV contrast	Usually Not Appropriate	O
MRI pelvis without IV contrast	Usually Not Appropriate	O
MRU without and with IV contrast	Usually Not Appropriate	O
MRU without IV contrast	Usually Not Appropriate	O

Panel Members

Daniel N. Costa, MD^a, Michael Bass, MD^b, Brian C. Allen, MD^c, Baris Turkbey, MD^d, Sarah Ahmad, MD^e, Marielia Gerena, MD^f, Carla Harmath, MD^g, Niels V. Johnsen, MD, MPH^h, Tasneem Lalani, MDⁱ, Susan B. Promes, MD, MBA^j, Lilja B. Solnes, MD, MBA^k, Scott D. Steenburg, MD^l, Ryan D. Ward, MD^m, Pat Whitworth III, MDⁿ, Gaurav Khatri, MD^o

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (ie, only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (ie, more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1:Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.

Variant 1:Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.
A. CT abdomen and pelvis with IV contrast

Variant 1:Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.
B. CT abdomen and pelvis without and with IV contrast

Variant 1:Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.
C. CT abdomen and pelvis without IV contrast

Variant 1:Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.
D. CTU without and with IV contrast

Variant 1:Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.
E. MRI abdomen and pelvis without and with IV contrast

Variant 1:Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.
F. MRI abdomen and pelvis without IV contrast

Variant 1:Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.
G. MRI abdomen without and with IV contrast

Variant 1:Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.
H. MRI abdomen without IV contrast

Variant 1:Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.
I. MRU without and with IV contrast

Variant 1:Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.
J. MRU without IV contrast

Variant 1:Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.
K. Radiography intravenous urography

Variant 1:Adult. Penetrating trauma, abdomen and pelvis. Suspected upper urinary tract trauma. Initial imaging.
L. US kidneys and bladder retroperitoneal

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
A. CT abdomen and pelvis with IV contrast

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
B. CT abdomen and pelvis without and with IV contrast

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
C. CT abdomen and pelvis without IV contrast

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
D. CT pelvis with bladder contrast (CT cystography)

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
E. CT pelvis with IV contrast

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
F. CT pelvis without and with IV contrast

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
G. CT pelvis without IV contrast

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
H. CTU without and with IV contrast

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
I. Fluoroscopy retrograde cystography

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
J. Fluoroscopy retrograde urethrography

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
K. Fluoroscopy voiding cystourethrography

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
L. MRI abdomen and pelvis without and with IV contrast

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
M. MRI abdomen and pelvis without IV contrast

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
N. MRI pelvis without and with IV contrast

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
O. MRI pelvis without IV contrast

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
P. MRU without and with IV contrast

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
Q. MRU without IV contrast

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
R. Radiography intravenous urography

Variant 2:Adult. Penetrating trauma, lower abdomen and pelvis. Suspected lower urinary tract trauma. Initial imaging.
S. US pelvis (bladder and urethra)

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Serafetinides E, Kitrey ND, Djakovic N, et al. Review of the current management of upper urinary tract injuries by the EAU Trauma Guidelines Panel. [Review]. European Urology. 67(5):930-6, 2015 May.Eur Urol. 67(5):930-6, 2015 May.
2.	Shyu JY, Khurana B, Soto JA, et al. ACR Appropriateness Criteria® Major Blunt Trauma. J Am Coll Radiol 2020;17:S160-S74.
3.	Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. Urotrauma Guideline 2020: AUA Guideline. J Urol. 2021 Jan;205(1):30-35.
4.	Dane B, Baxter AB, Bernstein MP. Imaging Genitourinary Trauma. Radiol Clin North Am. 2017 Mar;55(2):S0033-8389(16)30154-3.
5.	Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. Journal of Urology. 192(2):327-35, 2014 Aug.J Urol. 192(2):327-35, 2014 Aug.
6.	Lumen N, Kuehhas FE, Djakovic N, et al. Review of the current management of lower urinary tract injuries by the EAU Trauma Guidelines Panel. [Review]. European Urology. 67(5):925-9, 2015 May.Eur Urol. 67(5):925-9, 2015 May.
7.	Bryk DJ, Zhao LC. Guideline of guidelines: a review of urological trauma guidelines. [Review]. BJU International. 117(2):226-34, 2016 Feb.
8.	Shenfeld OZ, Gnessin E. Management of urogenital trauma: state of the art. Curr Opin Urol. 2011; 21(6):449-454.
9.	Ingram MD, Watson SG, Skippage PL, Patel U. Urethral injuries after pelvic trauma: evaluation with urethrography. [Review] [14 refs]. Radiographics. 28(6):1631-43, 2008 Oct.
10.	Chapple CR. Urethral injury. BJU Int. 2000; 86(3):318-326.
11.	Coccolini F, Moore EE, Kluger Y, et al. Kidney and uro-trauma: WSES-AAST guidelines. World J Emerg Surg. 2019;14():54.
12.	Schneider RE.. Genitourinary trauma. Emerg Med Clin North Am. 11(1):137-45, 1993 Feb.
13.	Bock SA, Sampson HA, Atkins FM, et al. Double-blind, placebo-controlled food challenge (DBPCFC) as an office procedure: a manual. J Allergy Clin Immunol. 1988 Dec;82(6):986-97.
14.	Corriere JN, Jr., Sandler CM. Diagnosis and management of bladder injuries. Urol Clin North Am. 2006; 33(1):67-71, vi.
15.	Jankowski JT, Spirnak JP. Current recommendations for imaging in the management of urologic traumas. Urol Clin North Am. 2006 Aug;33(3):365-76.
16.	Sandler CM, Hall JT, Rodriguez MB, Corriere JN. Bladder injury in blunt pelvic trauma. Radiology. 1986 Mar;158(3):633-8.
17.	Sandler CM, Goldman SM, Kawashima A. Lower urinary tract trauma. World J Urol. 1998;16(1):69-75.
18.	Horstman WG, McClennan BL, Heiken JP. Comparison of computed tomography and conventional cystography for detection of traumatic bladder rupture. Urol Radiol. 1991;12(4):188-93.
19.	Yeung LL, McDonald AA, Como JJ, et al. Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019 Feb;86(2):326-336.
20.	Carroll PR, McAninch JW. Major bladder trauma: the accuracy of cystography. J Urol. 1983 Nov;130(5):887-8.
21.	Chou CP, Huang JS, Wu MT, et al. CT voiding urethrography and virtual urethroscopy: preliminary study with 16-MDCT. AJR Am J Roentgenol. 2005 Jun;184(6):1882-8.
22.	Hsieh CH, Chen RJ, Fang JF, et al. Diagnosis and management of bladder injury by trauma surgeons. Am J Surg. 2002 Aug;184(2):143-7.
23.	Chan DP, Abujudeh HH, Cushing GL, Novelline RA. CT cystography with multiplanar reformation for suspected bladder rupture: experience in 234 cases. AJR Am J Roentgenol. 2006 Nov;187(5):1296-302.
24.	Bigongiari LR, Zarnow H. Traumatic, Inflammatory, Neoplastic, and Miscellaneous Lesions of the Bladder. In: Lang EK, ed. Radiology of the Lower Urinary Tract. Berlin, Heidelberg: Springer Berlin Heidelberg; 1994:69-147.
25.	Kim B, Kawashima A, LeRoy AJ. Imaging of the male urethra. Semin Ultrasound CT MR. 2007 Aug;28(4):258-73.
26.	Koraitim MM, Reda IS. Role of magnetic resonance imaging in assessment of posterior urethral distraction defects. Urology. 2007 Sep;70(3):403-6.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.