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General Guideline Title ACR Appropriateness Criteria® suspected lower urinarytract trauma. Bibliographic Source(s)
General Guideline Title ACR Appropriateness Criteria® suspected lower urinarytract trauma. Bibliographic Source(s)

General

Guideline Title

ACR Appropriateness Criteria® suspected lower urinarytract trauma.

Bibliographic Source(s)

Lockhart ME, Remer EM, Leyendecker JR, Eberhardt SC, FriedmanB, HartmanMS, HosseinzadehK, Lazarus E, Oto A, Porter C, SudakoffGS, Verma S, Expert PanelonUrologic Imaging. ACR Appropriateness Criteria® suspected lower urinarytract trauma. [online publication]. Reston(VA):AmericanCollege ofRadiology(ACR); 2013. 10 p. [54 references]

Guideline Status

This is the current release ofthe guideline.

This guideline updates a previous version:Arellano RS, Francis IR, Casalino DD, BaumgartenDA, CurryNS, Dighe M, FulghamP, IsraelGM, Leyendecker JR, PapanicolaouN, Prasad S, RamchandaniP, Remer EM, ShethS, Expert PanelonUrologic Imaging. ACR Appropriateness Criteria® suspected lower urinarytract trauma. [online publication]. Reston(VA):AmericanCollege ofRadiology(ACR); 2009. 7 p.

Recommendations

Major Recommendations

ACR Appropriateness Criteria®

ClinicalCondition:Suspected Lower UrinaryTract Trauma

Variant 1:Penetratingtrauma, lower abdomen/pelvis.

Radiologic Procedure

Rating

Comments

RRL*

X-rayretrograde cystography

8

 
X-rayretrograde cystography 8  
X-rayretrograde cystography 8  
X-rayretrograde cystography 8  

CT pelvis withbladder contrast (CT cystography)

8

A

CT cystogramand retrograde cystogramare

CT pelvis withbladder contrast (CT cystography) 8 A CT cystogramand retrograde cystogramare
CT pelvis withbladder contrast (CT cystography) 8 A CT cystogramand retrograde cystogramare
CT pelvis withbladder contrast (CT cystography) 8 A CT cystogramand retrograde cystogramare
CT pelvis withbladder contrast (CT cystography) 8 A CT cystogramand retrograde cystogramare

equivalent, but CT has become the first-line choice for acute trauma imaging. IfCT has beenperformed, a CT cystogramis preferable.

 

CT pelvis withcontrast

5

Routine enhanced CT alone is inadequate to evaluate the lower urinarytract for trauma. CT maybe needed

withcontrast 5 Routine enhanced CT alone is inadequate to evaluate the lower urinarytract for trauma. CT
withcontrast 5 Routine enhanced CT alone is inadequate to evaluate the lower urinarytract for trauma. CT
withcontrast 5 Routine enhanced CT alone is inadequate to evaluate the lower urinarytract for trauma. CT

to

evaluate extraurinarypelvic organs.

X-raypelvis

Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate

5

Performthis procedure ifthere is anyquestionofthe

*Relative

presence ofa foreignbody(e.g., bullet).

Radiation

X-rayretrograde Radiologic urethrography Procedure

 

Rating

5

Performthis procedure Comments ifthere is a suspected urethral

RRL*

RRL*
RRL*
RRL*
   

injury(e.g., trajectoryofknife or bullet).

 

CT pelvis without contrast

 

4

Routine unenhanced CT is inadequate to evaluate the lower urinarytract for trauma, but it maydetect free fluid to suggest further evaluation.

CT is inadequate to evaluate the lower urinarytract for trauma, but it maydetect free fluid to
CT is inadequate to evaluate the lower urinarytract for trauma, but it maydetect free fluid to
CT is inadequate to evaluate the lower urinarytract for trauma, but it maydetect free fluid to

CT pelvis without and withcontrast

 

3

There is added radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.

withcontrast   3 There is added radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.
withcontrast   3 There is added radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.
withcontrast   3 There is added radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.
withcontrast   3 There is added radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.

Arteriographywithpossible embolizationabdomenand pelvis

 

3

Use this procedure as a preliminaryto embolotherapy ifthere is persistent bleeding.

Varies

X-rayintravenous urography

 

2

This procedure is inadequate for lower urinarytract trauma.

X-rayintravenous urography   2 This procedure is inadequate for lower urinarytract trauma.
X-rayintravenous urography   2 This procedure is inadequate for lower urinarytract trauma.
X-rayintravenous urography   2 This procedure is inadequate for lower urinarytract trauma.

US pelvis (bladder and urethra)

 

2

US is usuallynot definitive.

O

MRI pelvis without and withcontrast

 

1

This procedure is not applicable to acute trauma.

O

MRI pelvis without contrast

 

1

This procedure is not applicable to acute trauma.

O

Tc-99mMAG3 scankidney

 

1

This procedure is not applicable to acute trauma.

Tc-99mMAG3 scankidney   1 This procedure is not applicable to acute trauma.
Tc-99mMAG3 scankidney   1 This procedure is not applicable to acute trauma.
Tc-99mMAG3 scankidney   1 This procedure is not applicable to acute trauma.

Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate

*Relative

Radiation

Level

Note:Abbreviations used inthe tables are listed at the end ofthe "Major Recommendations"field.

 

Variant 2:Blunt trauma, lower abdomen/pelvis.

 

Radiologic Procedure

 

Rating

Comments

RRL*

X-raypelvis

 

9

 
X-raypelvis   9  
X-raypelvis   9  

X-rayretrograde cystography

 

8

 
X-rayretrograde cystography   8  
X-rayretrograde cystography   8  
X-rayretrograde cystography   8  

CT pelvis withbladder contrast (CT cystography)

 

8

A CT cystogramand retrograde cystogramare equivalent, but CT has become the first-line choice for acute trauma imaging. IfCT is performed, a CT cystogramis preferable.

but CT has become the first-line choice for acute trauma imaging. IfCT is performed, a CT
but CT has become the first-line choice for acute trauma imaging. IfCT is performed, a CT
but CT has become the first-line choice for acute trauma imaging. IfCT is performed, a CT
but CT has become the first-line choice for acute trauma imaging. IfCT is performed, a CT

X-rayretrograde urethrography

 

5

This procedure is necessaryifa pelvic fracture is present or ifthe patient has hematuria and a negative cystogramor the inabilityto pass a Foleycatheter.

pelvic fracture is present or ifthe patient has hematuria and a negative cystogramor the inabilityto pass
pelvic fracture is present or ifthe patient has hematuria and a negative cystogramor the inabilityto pass
pelvic fracture is present or ifthe patient has hematuria and a negative cystogramor the inabilityto pass

CT pelvis withcontrast

 

5

Routine enhanced CT alone is inadequate to evaluate the lower urinarytract for trauma. It maybe needed to evaluate extraurinarypelvic organs. Include delayed images to detect ureteralinjuryifthere is periureteral fluid.

to evaluate extraurinarypelvic organs. Include delayed images to detect ureteralinjuryifthere is periureteral fluid.
to evaluate extraurinarypelvic organs. Include delayed images to detect ureteralinjuryifthere is periureteral fluid.
to evaluate extraurinarypelvic organs. Include delayed images to detect ureteralinjuryifthere is periureteral fluid.

CT pelvis without contrast

 

4

Routine unenhanced CT is inadequate to evaluate the lower urinarytract for trauma, but it maydetect free fluid to suggest further evaluation.

CT is inadequate to evaluate the lower urinarytract for trauma, but it maydetect free fluid to
CT is inadequate to evaluate the lower urinarytract for trauma, but it maydetect free fluid to
CT is inadequate to evaluate the lower urinarytract for trauma, but it maydetect free fluid to

CT pelvis without and withcontrast

 

3

This procedure adds radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.

  3 This procedure adds radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.
  3 This procedure adds radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.
  3 This procedure adds radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.
  3 This procedure adds radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.

Arteriographywithpossible embolizationabdomenand pelvis

 

3

Use this procedure as a preliminaryto embolotherapy for persistent bleeding.

Varies

X-rayintravenous urography

 

3

This procedure is inadequate for lower urinarytract trauma.

X-rayintravenous urography   3 This procedure is inadequate for lower urinarytract trauma.
X-rayintravenous urography   3 This procedure is inadequate for lower urinarytract trauma.
X-rayintravenous urography   3 This procedure is inadequate for lower urinarytract trauma.

US pelvis (bladder and urethra)

 

2

US is usuallynot definitive.

O

MRI pelvis without and withcontrast

 

1

This procedure is not applicable to acute trauma.

O

MRI pelvis without contrast

 

1

This procedure is not applicable to acute trauma.

O

Tc-99mMAG3 Radiologic scankidney Procedure

1

Rating

This procedure is not Comments applicable to acute trauma.

RRL*
RRL*
RRL*

RRL*

Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate

*Relative

Radiation

Level

Note:Abbreviations used inthe tables are listed at the end ofthe "Major Recommendations"field.

 

Variant 3:Blunt perinealtrauma inthe male (straddle injury).

 

Radiologic Procedure

Rating

Comments

RRL*

X-rayretrograde urethrography

9

 
X-rayretrograde urethrography 9  
X-rayretrograde urethrography 9  
X-rayretrograde urethrography 9  

X-raypelvis

9

This procedure canbe combined withretrograde urethrography.

X-raypelvis 9 This procedure canbe combined withretrograde urethrography.
X-raypelvis 9 This procedure canbe combined withretrograde urethrography.

CT pelvis withcontrast

7

 
CT pelvis withcontrast 7  
CT pelvis withcontrast 7  
CT pelvis withcontrast 7  

CT pelvis without and withcontrast

3

This procedure adds radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.

withcontrast 3 This procedure adds radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.
withcontrast 3 This procedure adds radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.
withcontrast 3 This procedure adds radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.
withcontrast 3 This procedure adds radiationwithout increased diagnostic improvement beyond CT withcontrast for trauma.

CT pelvis without contrast

1

This procedure is not sufficient to diagnose urethralor bladder injury. It maydetect free fluid or fracture.

contrast 1 This procedure is not sufficient to diagnose urethralor bladder injury. It maydetect free fluid
contrast 1 This procedure is not sufficient to diagnose urethralor bladder injury. It maydetect free fluid
contrast 1 This procedure is not sufficient to diagnose urethralor bladder injury. It maydetect free fluid

X-rayintravenous urography

1

This procedure is inadequate for lower urinarytract trauma.

X-rayintravenous urography 1 This procedure is inadequate for lower urinarytract trauma.
X-rayintravenous urography 1 This procedure is inadequate for lower urinarytract trauma.
X-rayintravenous urography 1 This procedure is inadequate for lower urinarytract trauma.

MRI pelvis without and withcontrast

1

This procedure is not applicable to acute trauma.

O

MRI pelvis without contrast

1

This procedure is not applicable to acute trauma.

O

Arteriographywithpossible embolizationabdomenand pelvis

1

Use this procedure as a preliminaryto embolotherapy for persistent bleeding.

Varies

US pelvis (bladder and urethra)

1

A transabdominalUS not definitive.

O

X-rayretrograde cystography

1

 
X-rayretrograde cystography 1  
X-rayretrograde cystography 1  
X-rayretrograde cystography 1  

Tc-99mMAG3 scankidney

1

This procedure is not applicable to acute trauma.

Tc-99mMAG3 scankidney 1 This procedure is not applicable to acute trauma.
Tc-99mMAG3 scankidney 1 This procedure is not applicable to acute trauma.
Tc-99mMAG3 scankidney 1 This procedure is not applicable to acute trauma.

Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate

*Relative

Radiation

Level

Note:Abbreviations used inthe tables are listed at the end ofthe "Major Recommendations"field.

SummaryofLiterature Review

Introduction/Background

Lower urinarytract injurycanbe caused byblunt, penetrating, or iatrogenic trauma. Injuries to the urologic systemoccur in10% to 20% of patients who experience major trauma and canbe the result ofeither blunt or penetratinginjuries. Ina series of31,380 trauma patients withpelvic fractures, bladder injurywas present in3% to 4% ofpatients. Major bladder injuryoccurs inabout 10% ofpatients sufferingfromananterior arch pelvic fracture. The presence or absence ofpelvic fractures alone does not always predict the type oflower urinarytract injury. Approximately 25% ofintraperitonealbladder ruptures occur inpatients who do not have a pelvic fracture. Concurrent bladder ruptures are present in10% to 29% ofmale patients witha traumatic rupture ofthe prostatomembranous urethra, withanaverage of3.1 associated injuries per patient.

The degree ofbladder distensionwithurine determines its shape and, to some degree, the injuryit maysustain. Evenrelativelyminor trauma can rupture the fullydistended bladder; the emptybladder is seldominjured, except bycrushingor penetratingwounds.

Gross hematuria indicates urologic trauma. The presence ofgross blood at the urethralmeatus stronglysuggests urethralinjury. A Foleycatheter should not be inserted without first doinga retrograde urethrogramto ensure urethralintegrity. Althoughgrosslyclear urine ina trauma patient without a pelvic fracture virtuallyeliminates the possibilityofa bladder rupture, up to 2% ofpatients witha bladder rupture mayhave only microhematuria.

Exactlyhow muchblood inthe urine necessitates investigationis a point ofcontroversyinthe literature. Published data suggest that bladder imaging

is not necessaryfor patients who have less than50 red blood cells/highpower field (RBC/hpf) oninitialpresentationand that no cases ofbladder injurywere missed, evenwhenpatients had more than50 RBC/hpfwithout gross hematuria.

Authors ofone studyindicated that cystographyused to evaluate blunt trauma should be restricted to patients withgross hematuria, whichthe authors defined as more than200 RBC/hpf. Theyalso recommended that a retrograde urethrogramshould be done first inmales who had a pelvic fracture. Inanother study, 90% of103 patients witha pelvic fracture did not have a bladder rupture; therefore, the authors concluded that cystographymaybe safelyreserved for patients withpelvic fractures who are considered to be at highrisk for suchaninjury. Theylimited cystographyinpelvic fracture to patients withsignificant pubic archinvolvement, gross hematuria, and/or hemodynamic instability.

Bladder Injury

The Consensus Panelofthe Société Internationale D'Urologie has classified bladder injuryinto 4 categories:

Type I:bladder contusionhas classified bladder injuryinto 4 categories: Type II:intraperitonealrupture Type

Type II:intraperitonealrupturebladder injuryinto 4 categories: Type I:bladder contusion Type III:extraperitonealrupture Type IV:combined injury A

Type III:extraperitonealruptureType I:bladder contusion Type II:intraperitonealrupture Type IV:combined injury A bladder contusion(type I) is

Type IV:combined injuryII:intraperitonealrupture Type III:extraperitonealrupture A bladder contusion(type I) is anincomplete tear ofthe

A bladder contusion(type I) is anincomplete tear ofthe bladder mucosa followingblunt injury. The results ofcystographyare normal. The

diagnosis ofa bladder contusionis usuallyestablished byexclusioninpatients who have hematuria followinga blunt pelvic trauma for whichno other cause is found. A bladder contusionis generallyregarded as the most commonformofbladder injuryfollowinga blunt trauma, but it is not considered to be a major injury.

Anintraperitonealrupture (type II) occurs whenthere is a suddenrise inintravesicalpressure resultingfroma blow to the lower abdomenofa patient witha distended bladder. The increased intravesicalpressure results ina rupture ofthe weakest portionofthe bladder, the dome, where the bladder is incontact withthe peritonealsurface. Intraperitonealrupture accounts for approximatelyone-third ofmajor bladder injuries. Approximately25% ofsuchinjuries occur inpatients who do not have a pelvic fracture. Oncystography, contrast materialextravasationinto the paracolic gutters and outliningloops ofthe smallbowelwillbe present. Oncomputed tomography(CT), there maybe a "sentinelclot"at the bladder dome inup to 80% ofpatients.

Anextraperitonealbladder rupture (type III) is classicallydescribed as the result ofa lacerationofthe bladder bya bone spicule inassociationwith ananterior pelvic archfracture. Recent data, however, have shownthat cystograms insuchpatients oftendemonstrate that the site ofcontrast materialextravasationis far removed fromthe site offracture; thus, the validityofthis mechanismhas beenquestioned. Extraperitonealrupture represents approximately60% ofmajor bladder injuries. Authors ofone studyfurther subdivided extraperionealrupture into two groups. With simple extraperitonealrupture, contrast extravasationis limited to the pelvic extraperitonealspace. Withcomplexextraperitonealrupture, contrast materialextravasationmayextend into the anterior abdominalwall, the penis, the scrotum, and the perineum. The presence ofa complex extraperitonealinjuryimplies that the injuryhas disrupted the fascialboundaries ofthe pelvis. Suchfindings should not be mistakenas evidence ofa coexistingurethralinjury. Surgicalrepair ofanextraperitonealrupture varies byinstitutionand whether other surgeryis needed, but it canoccur in more thanhalfofpatients.

A combined bladder injury(type IV) results whenbothintraperitonealand extraperitonealbladder injuries are present. This represents

approximately5% ofmajor bladder injuries.

UrethralInjury

Injuries to the male urethra canbe classified into 2 maincategories accordingto their mechanismofinjury:1) those associated witha fracture ofthe anterior pelvic arch(usuallyinvolvingthe membranous urethra), and 2) those occurringas the result ofa straddle injury(usuallyinvolvingthe bulbous urethra). Anterior urethralinjuries are less commonthanposterior injuries.

Anyfemale urethralinjuryis rare and is usuallyassociated withpelvic disruptionand/or vaginallaceration. The incidence ofurethralinjurywith pelvic fracture ranges from0% to 6% inwomenand canbe as muchas 10% inmen. Ina series of31,380 trauma patients withpelvic fractures, urethralinjurywas present in0.15% ofwomenversus 1.5% ofmen. This is due to the relativelyshort lengthand anatomic positionofthe female urethra, whichis hiddenbehind the osseous pubic arch, and the fact that it is more mobile, without significant attachment to the pubic bone.

Inmenwho sustaina pelvic fracture, urethralinjuryoccurs whenthe prostate is sheared fromits connectionto the urogenitaldiaphragm, as the puboprostatic ligaments are ruptured. The urethralinjuryis due to disruptionofthe soft tissues, rather thanto a lacerationbya bonyspicule. A hematoma forms inthe retropubic and perivesicalspaces.

Straddle injuries occur as the result ofa direct blow to the perineumwhenthe urethra and corpus spongiosa are compressed betweena hard object and the inferior aspect ofthe symphysis pubis. Inmost cases, there is no pelvic fracture. Straddle injuries result ineither partialor complete rupture ofthe bulbous urethra.

Male urethraltrauma has beenclassified based onthe appearance ofthe retrograde urethrogram. This classificationhas beenexpanded to include allurethraltrauma.

Urethralinjuries associated withpelvic fracture include:

Type I:posterior urethra stretched but intactUrethralinjuries associated withpelvic fracture include: Type II:urethra disrupted at the membranoprostatic

Type II:urethra disrupted at the membranoprostatic junctionabove the urogenitaldiaphragminclude: Type I:posterior urethra stretched but intact Type III:membranous urethra disrupted, withextensionto the

Type III:membranous urethra disrupted, withextensionto the proximalbulbous urethra, and/or disruptionofthe urogenitaldiaphragm(most common)the membranoprostatic junctionabove the urogenitaldiaphragm Type IV:bladder neck injury, withextensioninto the urethra

Type IV:bladder neck injury, withextensioninto the urethraand/or disruptionofthe urogenitaldiaphragm(most common) Type IVa:injuryto the base ofthe bladder,

Type IVa:injuryto the base ofthe bladder, withperiurethralextravasationsimulatinga true type IV urethralinjuryType IV:bladder neck injury, withextensioninto the urethra Type V:partialor complete pure anterior urethralinjury There

Type V:partialor complete pure anterior urethralinjurytrue type IV urethralinjury There has beenrecent work involvingthe treatment ofpelvic

There has beenrecent work involvingthe treatment ofpelvic fracture-related urethralinjuryinvolvingthe prostatic urethra, withextensioninto the bladder neck. It is important to recognize this type so that anearlyrepair canbe performed because these injuries do not healspontaneouslyand are associated withincontinence.

Retrograde Urethrography(RUG)

Urethrographyhas improved our understandingofthe mechanismofsuchinjuries. Inthe past, a diagnosis ofacute urethralinjuryoftenwas based looselyonthe clinicaltriad of1) blood at the urethralmeatus, 2) inabilityofthe patient to void, and 3) a palpable urinarybladder. Aninabilityto pass the catheter into the bladder was also considered diagnostic ofa posterior urethralinjury. It is now wellestablished, however, that diagnostic catheterizationis to be avoided, as it mayconvert a partialinjuryinto a complete one. Because posterior urethralinjuries are also seenwithpelvic fractures, a retrograde urethrogramshould be performed before insertinga catheter. Lack ofpelvic and suprapubic tenderness; absence ofpenile, scrotal, or perinealhematoma; and a normalrectalexaminationsupport the integrityofthe urethra. Patients withpenetratingtrauma to the penis should undergo RUG as the primarydiagnostic procedure.

Cystography

The diagnosis ofbladder rupture is usuallyeasywithcystography, whenthe injected contrast is identified outside the bladder. Prior to the widespread acceptance ofCT cystographyas anequivalent alternative inevaluatingbladder trauma, retrograde cystographyhas beencalled the "procedure ofchoice,""mandatory,""the onlyway,""examinationofchoice,""keystone,""mainstay,"and "absolute indication."

Adequate distentionofthe urinarybladder is crucialto findinga perforation, especiallyininstances ofpenetratingtrauma, as most instances ofa false-negative retrograde cystogramwere found inthis situation. To exclude bladder injury, a fillingvolume ofat least 350–400 mL contrast should be achieved. The catheter balloonshould not be tightlymaintained against the bladder neck because it could tamponade against a disruptionand prevent detectionofa leak inthis region.

Cystographyrequires scout radiograph, filled view, and postdrainage radiograph, at a minimum. Fluoroscopic visualizationduringearlyfilling should be obtained to avoid additionaldistensionifa gross disruptionis identified. Obliques are usefulto avoid missinga smallanterior or posterior injury. Inapproximately10% ofcases, bladder injurycanbe identified onlywiththe postdrainage image. Cystographyhas anaccuracyrate of 85% to 100% for detectingbladder injury. However, onlya properlyperformed cystogramshould be used to exclude bladder injury.

Intravenous Urography(IVU)

AnIVU is inadequate for evaluatingthe bladder and urethra after trauma because the contrast materialwithinthe bladder is diluted and because the restingintravesicalpressure is simplytoo low to demonstrate a smalltear. IVU has a low accuracy, onthe order of15% to 25%. Anaccurate diagnosis ofbladder rupture was made withIVU inonly5 of23 studypatients (22%). One studyfound anaccurate diagnosis for only5 of32 (16%) patients, and another studyfound anaccuracyrate for only4 of11 (36%).

Ultrasound (US)

TransabdominalUS findings inbladder rupture and urethralevaluationwithanendorectalprobe have beendescribed, but US has not been routinelyused for evaluatingthe trauma patient. It is unlikelythat a patient withsignificant posterior urethralor bladder rupture would tolerate evaluationbyanendorectalprobe. Onthe other hand, most or allserious trauma patients willlikelybe evaluated withCT because ofits speed and

accuracyofevaluation.

US canbe used to evaluate associated viscerallesions, suchas solid or hollow organrupture and nonspecific peritonealfluid. However, ina series of128 acute trauma patients, 11 of19 injuries that were missed byemergent US involved the genitourinarysystem. The detectionofperitoneal fluid inthe presence ofnormalviscera or the failure to visualize the bladder after the transurethralintroductionofsaline are considered highly suggestive ofbladder rupture. As a practicalmatter, US is not definitive inbladder or urethraltrauma and is almost never used.

Computed Tomography

CT cystographyhas become the first-line evaluationfor bladder injuryinthe acute trauma setting. This technique refers to the retrograde instillation ofa minimumof350 cc ofdiluted contrast media into the bladder, followed byaxialand coronalCT images ofthe pelvis. Unlike conventional cystography, no postdrainage CT images are needed. Authors ofone studyreported sensitivities of95% overallbut only78% for intraperitoneal rupture. Inanother studywith100% sensitivityand 99% specificityfor intraperitonealbladder rupture, the specific site ofdome injuries in4 of18 patients were identified onlywithmultiplanar reconstructed images. A bladder contusionmaynot be visible byCT cystography. Routine CT, using excreted contrast only, cannot be relied onentirelyto diagnose bladder rupture, evenwitha urethralcatheter inserted and clamped. CT performed withexcreted contrast onlycandemonstrate intraperitonealor extraperitonealfluid, but it cannot differentiate urine fromascites. However, the absence ofpelvic ascites is strongevidence against a bladder rupture. As withIVU, the bladder is usuallyinadequatelydistended to cause extravasationthrougha bladder lacerationor perforationduringroutine abdominaland pelvic studies. A negative studydoes not exclude bladder injury.

Researchers reviewed the examinations of25 patients who received bothcystograms and CT inthe initialevaluationofa blunt abdominaltrauma. Five had a bladder rupture; 3 were extraperitoneal, and 2 were intraperitoneal. Allinjuries were detected bybothstudies. The authors felt that delayed imagingor contrast instillationduringCT canprovide the adequate bladder distentionneeded to demonstrate contrast extravasationfrom the injurysite. Theycontinued to performcystographyinpatients withcompellingevidence ofa bladder injury, but no extravasationwas demonstrated byCT. The author ofanother studystated that either retrograde cystographyor CT is the diagnostic procedure ofchoice for a suspected bladder injury.

The literature suggests that bothconventionaland CT cystographyare equivalent, withphysicianpreference and diagnostic protocols generally definingthe method used. One studyprospectivelycompared CT cystographyand conventionalcystographyinpatients withblunt abdominal trauma and found equallyhighsensitivity(95%) and specificity(100%) for bothtechniques. AlthoughCT is not the technique ofchoice for urethral injuries, it is performed so frequentlythat urethralinjuries are inevitablyidentified whenCT is performed for pelvic trauma. Findings caninclude displacement ofthe prostate and bladder, extravasationofcontrast media, and hematomas. Recently, researchers described the preliminaryresults ofCT voidingurethrographyusing16-multidetector CT and found a highcorrelationbetweenthe results ofconventionalRUG and CT voiding urethrographyfor evaluatingurethralinjuries.

Angiography

Angiographycanbe usefulinidentifyinganoccult source ofbleedingand canguide its subsequent therapeutic embolization.

Nuclear Imaging

Because ofits low resolution, nuclear imaginghas not beenapplied to lower urinarytract injuries.

Magnetic Resonance Imaging(MRI)

Because ofthe difficultyofmonitoringa seriouslyinjured patient ina strongmagnetic field MRI currentlyplays a smallrole inevaluatingacute bladder and/or urethraltrauma. MRI use has beendescribed for later evaluationofurethralinjuryas anadjunctive toolfor assessingcomplex urethralanatomic derangements.

Summary

CT ofthe pelvis withbladder contrast (CT cystography) is the recommended imagingstudyfor suspected lower urinarytract injurydue to a penetratingtrauma ofthe lower abdomenor pelvis, because CT scans ofthe abdomenand pelvis are frequentlyobtained for abdominopelvic trauma. Routine unenhanced CT scans ofthe abdomenor pelvis alone maybe inadequate to assess for penetratinginjuries to the lower urinarytract system. Whena CT scanofthe abdomenor pelvis ina trauma patient is not alreadybeingobtained, theneither x- rayretrograde cystographyor CT cystographyis recommended to assess for bladder injury.assessingcomplex urethralanatomic derangements. Summary X-rayretrograde cystographyor pelvic CT withbladder contrast

X-rayretrograde cystographyor pelvic CT withbladder contrast (CT cystography) are the recommended imagingstudies for a suspected lower urinarytract injurydue to blunt trauma to the lower abdomenor pelvis. RUG should be considered, to exclude urethralinjury, when pelvic fracture is present. RUG should be performed inthe settingofgross hematuria to exclude urethralinjurybefore bladderalreadybeingobtained, theneither x- rayretrograde cystographyor CT cystographyis recommended to assess for bladder injury.

catheterization.

X-rayRUG is the examinationofchoice for a suspected blunt perinealtrauma inthe male (straddle injury) and should be performed for suspected urethralinjuryfroma penetratingtrauma.catheterization. Abbreviations CT, computed tomography MAG3, mercaptoacetyltriglycine MRI, magnetic resonance imaging Tc,

Abbreviations

CT, computed tomographyurethralinjuryfroma penetratingtrauma. Abbreviations MAG3, mercaptoacetyltriglycine MRI, magnetic resonance

MAG3, mercaptoacetyltriglycinepenetratingtrauma. Abbreviations CT, computed tomography MRI, magnetic resonance imaging Tc, technetium US,

MRI, magnetic resonance imagingCT, computed tomography MAG3, mercaptoacetyltriglycine Tc, technetium US, ultrasound Relative

Tc, technetiummercaptoacetyltriglycine MRI, magnetic resonance imaging US, ultrasound Relative RadiationLevelDesignations Relative

US, ultrasoundMRI, magnetic resonance imaging Tc, technetium Relative RadiationLevelDesignations Relative RadiationLevel*

Relative RadiationLevelDesignations

Relative RadiationLevel*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

0 mSv

<0.1 mSv <0.03 mSv

<0.1 mSv

<0.03 mSv

0.1-1 mSv 0.03-0.3 mSv
0.1-1 mSv 0.03-0.3 mSv

0.1-1 mSv

0.03-0.3 mSv

1-10 mSv 0.3-3 mSv
1-10 mSv 0.3-3 mSv
1-10 mSv 0.3-3 mSv

1-10 mSv

0.3-3 mSv

10-30 mSv 3-10 mSv
10-30 mSv 3-10 mSv
10-30 mSv 3-10 mSv
10-30 mSv 3-10 mSv

10-30 mSv

3-10 mSv

30-100 mSv 10-30 mSv
30-100 mSv 10-30 mSv
30-100 mSv 10-30 mSv
30-100 mSv 10-30 mSv
30-100 mSv 10-30 mSv

30-100 mSv

10-30 mSv

*RRL assignments for some ofthe examinations cannot be made, because the actualpatient doses inthese procedures varyas a functionofa number offactors (e.g., regionofthe bodyexposed to ionizingradiation, the imagingguidance that is used). The RRLs for these examinations are designated as "Varies."

Clinical Algorithm(s)

Algorithms were not developed fromcriteria guidelines.

Scope

Disease/Condition(s)

Suspected lower urinarytract trauma

Guideline Category

Diagnosis

Evaluation

Clinical Specialty

EmergencyMedicine

Nuclear Medicine

Radiology

Urology

Intended Users

HealthPlans

Hospitals

Managed Care Organizations

Physicians

UtilizationManagement

Guideline Objective(s)

To evaluate the appropriateness ofradiologic examinations for patients withsuspected lower urinarytract trauma

Target Population

Patients withsuspected lower urinarytract trauma

Interventions and Practices Considered

1. X-ray

Pelvis

Pelvis

Retrograde cystography

Retrograde cystography

Retrograde urethrography

Retrograde urethrography

Intravenous urography

Intravenous urography

2. Computed tomography(CT) pelvis Withbladder contrast (CT cystography) Withcontrast Without contrast Without and withcontrast

3. Arteriographywithpossible embolizationabdomenand pelvis

4. Ultrasound (US) pelvis (bladder and urethra)

5. Magnetic resonance imaging(MRI) pelvis Without and withcontrast Without contrast

6. Technetium(Tc)-99mmercaptoacetyltriglycine (MAG3) scankidney

Technetium(Tc)-99mmercaptoacetyltriglycine (MAG3) scankidney Major Outcomes Considered Utilityofradiologic procedures
Technetium(Tc)-99mmercaptoacetyltriglycine (MAG3) scankidney Major Outcomes Considered Utilityofradiologic procedures
Technetium(Tc)-99mmercaptoacetyltriglycine (MAG3) scankidney Major Outcomes Considered Utilityofradiologic procedures
Technetium(Tc)-99mmercaptoacetyltriglycine (MAG3) scankidney Major Outcomes Considered Utilityofradiologic procedures
Technetium(Tc)-99mmercaptoacetyltriglycine (MAG3) scankidney Major Outcomes Considered Utilityofradiologic procedures
Technetium(Tc)-99mmercaptoacetyltriglycine (MAG3) scankidney Major Outcomes Considered Utilityofradiologic procedures

Major Outcomes Considered

Utilityofradiologic procedures inevaluationofsuspected lower urinarytract trauma

Methodology

Methods Used to Collect/Select the Evidence

Searches ofElectronic Databases

Description of Methods Used to Collect/Select the Evidence

Literature SearchProcedure

StaffwillsearchinPubMed onlyfor peer reviewed medicalliterature for routine searches. Anyarticle or guideline maybe used bythe author inthe narrative but those materials mayhave beenidentified outside ofthe routine literature searchprocess.

The Medline literature searchis based onkeywords provided bythe topic author. The two generalclasses ofkeywords are those related to the condition(e.g., ankle pain, fever) and those that describe the diagnostic or therapeutic interventionofinterest (e.g., mammography, MRI).

The searchterms and parameters are manipulated to produce the most relevant, current evidence to address the AmericanCollege ofRadiology Appropriateness Criteria (ACR AC) topic beingreviewed or developed. Combiningthe clinicalconditions and diagnostic modalities or therapeutic procedures narrows the searchto be relevant to the topic. Explodingthe term"diagnostic imaging"captures relevant results for diagnostic topics.

The followingcriteria/limits are used inthe searches.

1. Articles that have abstracts available and are concerned withhumans.

2. Restrict the searchto the year prior to the last topic update or insome cases the author ofthe topic mayspecifywhichyear range to use in the search. For new topics, the year range is restricted to the last 10 years unless the topic author provides other instructions.

3. Mayrestrict the searchto Adults onlyor Pediatrics only.

4. Articles consistingofonlysummaries or case reports are oftenexcluded fromfinalresults.

The searchstrategymaybe revised to improve the output as needed.

Number of Source Documents

The totalnumber ofsource documents identified as the result ofthe literature searchis not known.

Methods Used to Assess the Quality and Strength of the Evidence

WeightingAccordingto a RatingScheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

StrengthofEvidence Key

Category1 - The conclusions ofthe studyare valid and stronglysupported bystudydesign, analysis, and results.

Category2 - The conclusions ofthe studyare likelyvalid, but studydesigndoes not permit certainty.

Category3 - The conclusions ofthe studymaybe valid, but the evidence supportingthe conclusions is inconclusive or equivocal.

Category4 - The conclusions ofthe studymaynot be valid because the evidence maynot be reliable giventhe studydesignor analysis.

Methods Used to Analyze the Evidence

Systematic Review withEvidence Tables

Description of the Methods Used to Analyze the Evidence

The topic author drafts or revises the narrative text summarizingthe evidence found inthe literature. AmericanCollege ofRadiology(ACR) staff draft anevidence table based onthe analysis ofthe selected literature. These tables rate the strengthofthe evidence (studyquality) for eacharticle included inthe narrative text.

The expert panelreviews the narrative text, evidence table, and the supportingliterature for eachofthe topic-variant combinations and assigns an appropriateness ratingfor eachprocedure listed inthe table. Eachindividualpanelmember assigns a ratingbased onhis/her interpretationofthe available evidence.

More informationabout the evidence table development process canbe found inthe ACR Appropriateness Criteria® Evidence Table Development document (see the "AvailabilityofCompanionDocuments"field).

Methods Used to Formulate the Recommendations

Expert Consensus (Delphi)

Description of Methods Used to Formulate the Recommendations

RatingAppropriateness

The appropriateness ratings for eachofthe procedures included inthe Appropriateness Criteria topics are determined usinga modified Delphi methodology. A series ofsurveys are conducted to elicit eachpanelist's expert interpretationofthe evidence, based onthe available data, regardingthe appropriateness ofanimagingor therapeutic procedure for a specific clinicalscenario. AmericanCollege ofRadiology(ACR) staff distribute surveys to the panelists alongwiththe evidence table and narrative. Eachpanelist interprets the available evidence and rates each procedure. The surveys are completed bypanelists without consultingother panelists. The appropriateness ratingscale is anordinalscale that uses integers from1 to 9 grouped into three categories:1, 2, or 3 are inthe category"usuallynot appropriate"; 4, 5, or 6 are inthe category"maybe appropriate"; and 7, 8, or 9 are inthe category"usuallyappropriate."Eachpanelmember assigns one ratingfor eachprocedure for a clinical scenario. The ratings assigned byeachpanelmember are presented ina table displayingthe frequencydistributionofthe ratings without identifying whichmembers provided anyparticular rating.

Ifconsensus is reached, the medianratingis assigned as the panel's finalrecommendation/rating. Consensus is defined as eightypercent (80%) agreement withina ratingcategory. A maximumofthree rounds maybe conducted to reachconsensus. Consensus amongthe panelmembers must be achieved to determine the finalratingfor eachprocedure.

Ifconsensus is not reached, the panelis convened byconference call. The strengths and weaknesses ofeachimagingprocedure that has not reached consensus are discussed and a finalratingis proposed. Ifthe panelists onthe callagree, the ratingis proposed as the panel's consensus. The document is circulated to allthe panelists to make the finaldetermination. Ifconsensus cannot be reached onthe callor whenthe document is circulated, "No consensus"appears inthe ratingcolumnand the reasons for this decisionare added to the comment sections.

This modified Delphimethod enables eachpanelist to express individualinterpretations ofthe evidence and his or her expert opinionwithout excessive influence fromfellow panelists ina simple, standardized and economicalprocess. A more detailed explanationofthe complete process

canbe found inadditionalmethodologydocuments found onthe ACR Web site Documents"field).

(see also the "AvailabilityofCompanion

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formalcost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

InternalPeer Review

Description of Method of Guideline Validation

Criteria developed bythe Expert Panels are reviewed bythe AmericanCollege ofRadiology(ACR) Committee onAppropriateness Criteria.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The recommendations are based onanalysis ofthe current literature and expert panelconsensus.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Selectionofappropriate radiologic imagingprocedures for evaluationofpatients withsuspected lower urinarytract trauma

Potential Harms

Adequate distentionofthe urinarybladder is crucialto findinga perforation, especiallyininstances ofpenetratingtrauma, as most instances ofa false-negative retrograde cystogramwere found inthis situation.

Relative RadiationLevel(RRL)

Potentialadverse healtheffects associated withradiationexposure are animportant factor to consider whenselectingthe appropriate imaging procedure. Because there is a wide range ofradiationexposures associated withdifferent diagnostic procedures, a relative radiationlevel indicationhas beenincluded for eachimagingexamination. The RRLs are based oneffective dose, whichis a radiationdose quantitythat is used to estimate populationtotalradiationrisk associated withanimagingprocedure. Patients inthe pediatric age group are at inherentlyhigher risk from exposure, bothbecause oforgansensitivityand longer life expectancy(relevant to the longlatencythat appears to accompanyradiationexposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared to those specified for adults. Additional informationregardingradiationdose assessment for imagingexaminations canbe found inthe AmericanCollege ofRadiology(ACR) Appropriateness Criteria® RadiationDose Assessment Introductiondocument (see the "AvailabilityofCompanionDocuments"field).

Qualifying Statements

Qualifying Statements

The AmericanCollege ofRadiology(ACR) Committee onAppropriateness Criteria and its expert panels have developed criteria for determining appropriate imagingexaminations for diagnosis and treatment ofspecified medicalcondition(s). These criteria are intended to guide radiologists, radiationoncologists, and referringphysicians inmakingdecisions regardingradiologic imagingand treatment. Generally, the complexityand severityofa patient's clinicalconditionshould dictate the selectionofappropriate imagingprocedures or treatments. Onlythose examinations generallyused for evaluationofthe patient's conditionare ranked. Other imagingstudies necessaryto evaluate other co-existent diseases or other medicalconsequences ofthis conditionare not considered inthis document. The availabilityofequipment or personnelmayinfluence the selection ofappropriate imagingprocedures or treatments. Imagingtechniques classified as investigationalbythe U.S. Food and DrugAdministration(FDA) have not beenconsidered indevelopingthese criteria; however, studyofnew equipment and applications should be encouraged. The ultimate decisionregardingthe appropriateness ofanyspecific radiologic examinationor treatment must be made bythe referringphysicianand radiologist inlight ofallthe circumstances presented inanindividualexamination.

Implementation of the Guideline

Description of Implementation Strategy

Animplementationstrategywas not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

GettingBetter

IOM Domain

Effectiveness

Identifying Information and Availability

Bibliographic Source(s)

Lockhart ME, Remer EM, Leyendecker JR, Eberhardt SC, FriedmanB, HartmanMS, HosseinzadehK, Lazarus E, Oto A, Porter C, SudakoffGS, Verma S, Expert PanelonUrologic Imaging. ACR Appropriateness Criteria® suspected lower urinarytract trauma. [online publication]. Reston(VA):AmericanCollege ofRadiology(ACR); 2013. 10 p. [54 references]

Adaptation

Not applicable:The guideline was not adapted fromanother source.

Date Released

1996 (revised 2013)

Guideline Developer(s)

AmericanCollege ofRadiology- MedicalSpecialtySociety

Source(s) of Funding

The AmericanCollege ofRadiology(ACR) provided the fundingand the resources for these ACR Appropriateness Criteria®.

Guideline Committee

Committee onAppropriateness Criteria, Expert PanelonUrologic Imaging

Composition of Group That Authored the Guideline

Panel Members:Mark E. Lockhart, MD, MPH (Principal Author); Erick M. Remer, MD (Panel Chair); JohnR. Leyendecker, MD (Panel Vice-chair); StevenC. Eberhardt, MD; Barak Friedman, MD; Matthew S. Hartman, MD; KeyanooshHosseinzadeh, MD; ElizabethLazarus, MD; AytekinOto, MD; Christopher Porter, MD; GaryS. Sudakoff, MD; Sadhna Verma, MD

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release ofthe guideline.

This guideline updates a previous version:Arellano RS, Francis IR, Casalino DD, BaumgartenDA, CurryNS, Dighe M, FulghamP, IsraelGM, Leyendecker JR, PapanicolaouN, Prasad S, RamchandaniP, Remer EM, ShethS, Expert PanelonUrologic Imaging. ACR Appropriateness Criteria® suspected lower urinarytract trauma. [online publication]. Reston(VA):AmericanCollege ofRadiology(ACR); 2009. 7 p.

Guideline Availability

Electronic copies:Available fromthe AmericanCollege ofRadiology(ACR) Web site

.

Print copies:Available fromthe AmericanCollege ofRadiology, 1891 PrestonWhite Drive, Reston, VA 20191. Telephone:(703) 648-8900.

Availability of Companion Documents

The followingare available:

ACR Appropriateness Criteria®. Overview. Reston(VA):AmericanCollege ofRadiology; 2013 Nov. 3 p. Electronic copies:Available inof Companion Documents The followingare available: Portable Document Format (PDF) fromthe AmericanCollege

Portable Document Format (PDF) fromthe AmericanCollege ofRadiology(ACR) Web site

.

ACR Appropriateness Criteria®. Literature searchprocess. Reston(VA):AmericanCollege ofRadiology; 2013 Apr. 1 p. Electronic(PDF) fromthe AmericanCollege ofRadiology(ACR) Web site . copies:Available inPDF fromthe ACR Web site . ACR

copies:Available inPDF fromthe ACR Web site

.

ACR Appropriateness Criteria®. Evidence table development – diagnostic studies. Reston(VA):AmericanCollege ofRadiology; 2013p. Electronic copies:Available inPDF fromthe ACR Web site . Nov. 3 p. Electronic copies:Available inPDF fromthe

Nov. 3 p. Electronic copies:Available inPDF fromthe ACR Web site

.

ACR Appropriateness Criteria®. Radiationdose assessment introduction. Reston(VA):AmericanCollege ofRadiology; 2013 Nov. 3 p.p. Electronic copies:Available inPDF fromthe ACR Web site . Electronic copies:Available inPDF fromthe ACR Web site

Electronic copies:Available inPDF fromthe ACR Web site

.

ACR Appropriateness Criteria®. Manualoncontrast media. Reston(VA):AmericanCollege ofRadiology; 90 p. Electronic copies:p. Electronic copies:Available inPDF fromthe ACR Web site . Available inPDF fromthe ACR Web site .

Available inPDF fromthe ACR Web site

.

ACR Appropriateness Criteria®. Procedure information. Reston(VA):AmericanCollege ofRadiology; 2013 Apr. 1 p. Electronic copies:Electronic copies: Available inPDF fromthe ACR Web site . Available inPDF fromthe ACR Web site .

Available inPDF fromthe ACR Web site

.

ACR Appropriateness Criteria® suspected lower urinarytract trauma. Evidence table. Reston(VA):AmericanCollege ofRadiology;Electronic copies: Available inPDF fromthe ACR Web site . 2013. 17 p. Electronic copies:Available fromthe ACR

2013. 17 p. Electronic copies:Available fromthe ACR Web site

Patient Resources

None available

.

NGC Status

This NGC summarywas completed byECRI onFebruary13, 2006. This NGC summarywas updated byECRI Institute onDecember 6, 2007. This NGC summarywas updated byECRI Institute onJune 18, 2010. This NGC summarywas updated byECRI Institute onMarch7, 2014.

Copyright Statement

Instructions for downloading, use, and reproductionofthe AmericanCollege ofRadiology(ACR) Appropriateness Criteria® maybe found onthe

.

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