ACR Appropriateness Criteria® Penetrating Trauma-Abdomen and Pelvis: Update 2026

Penetrating urinary tract trauma requires timely imaging to correctly identify the location and extent of injury and guide management. In patients with suspected penetrating upper tract trauma, CT of the abdomen and pelvis with intravenous contrast and CT urography without and with contrast are usually appropriate for initial imaging, with CT urography providing superior evaluation of the collecting system and ureters. CT protocols without dedicated urographic phases may be appropriate in selected circumstances but provide limited assessment and should not replace CT urography when urinary tract injury is suspected. In patients with suspected penetrating lower tract trauma, fluoroscopic retrograde urethrography, contrast-enhanced CT of the abdomen and pelvis, and CT cystography are usually appropriate and may be complementary, allowing evaluation of the urethra, bladder, and other pelvic structures. Other CT or fluoroscopic examinations may be appropriate in select cases, whereas ultrasound and MRI-based techniques are usually not appropriate for initial evaluation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.