Constipation on abdominal radiograph as potential risk factor for recurrent urinary tract infection development



To compare clinical history and measurements of fecal load on abdominal radiography (AR) in the prediction of urinary tract infection (UTI) recurrence in children.


We combined data from two multicenter longitudinal studies in which children less than 6 years of age with a first or second UTI were followed for recurrence of UTI. Two radiologists reviewed the scout abdominal radiographs of initial voiding cystourethrograms obtained at enrollment from children at two participating sites and measured stool visible in various parts of the colon. We examined how well clinical variables (e.g., voiding and bowel history, use of laxatives at enrollment) and measurements of fecal load predicted recurrence of UTI within 12 months of enrollment.


One hundred and ninety-two children were included. On univariate analyses, age, vesicoureteral reflux (VUR), cecal diameter, rectal diameter, and total stool length on AR were associated with recurrence of UTI. After controlling for age, the odds of recurrent UTI in children with VUR at baseline was 3.85 (95% CI: 1.62, 9.14) higher than in children without VUR. Recurrent UTI was 2.57 (95% CI: 1.01, 6.55) times more likely in children with cecal diameter > 3.10 cm than children with lower cecal diameters; time to first recurrent UTI was shorter in children with elevated cecal diameters (p = 0.0023).


Cecal diameter on abdominal radiographs predicts UTI recurrence in children with a previous UTI. However, its accuracy is suboptimal to serve as a screening test. Accordingly, its routine use for this indication is not supported. If cecal diameter on an AR ordered for another indication is > 3.10 cm, then management of constipation could be considered.

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Fig. 1



Urinary tract infection


Vesicoureteral reflux


Randomized Intervention for Children with Vesicoureteral Reflux


Careful Urinary Tract Infection Evaluation study


Bladder and bowel dysfunction


Abdominal radiograph


Voiding cystourethrogram


Dimercaptosuccinic acid renal scan


Paris Consensus on Childhood Constipation Terminology


Odds ratio


Receiver operation characteristic curve


Area under the ROC curve


Kaplan-Meier curve


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We would like to acknowledge Ilina Rosoklija, MPH, and Bruce Lindgren, MD, from Lurie Children’s Hospital of Chicago Division of Pediatric Urology for their contribution and initial vision during the development of this manuscript.


The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Diabetes and Digestive and Kidney Diseases or the National Institutes of Health. This research was supported by grants U01 DK074059, U01 DK074053, U01 DK074082, U01 DK074064, U01 DK074062, and U01 DK074063 from the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services.

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Drs. Muniz and Shaikh conceptualized the study concept and design, participated in the acquisition of data, drafted the initial manuscript, and approved the final manuscript as submitted. Drs. Kar and Gumus participated in the study design, acquisition, and interpretation of data; drafted the initial manuscript; and approved the final manuscript as submitted. Ms. Liu participated in the analysis of data, drafted the initial manuscript, and approved the final manuscript as submitted. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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Correspondence to Nader Shaikh.

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The authors declare no competing interests.

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What’s known on this subject

Many articles have described a potential association between constipation and development of UTIs. We examined the presence and severity of fecal loading on abdominal radiographs of children diagnosed with UTIs as a potential predictor for recurrent infections.

What this study adds

We found that an increased cecal diameter on abdominal radiography was associated with UTI recurrence. These findings have important implications for the screening and treatment of constipation.

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Muniz, G., Kar, E., Gumus, S. et al. Constipation on abdominal radiograph as potential risk factor for recurrent urinary tract infection development. Pediatr Nephrol (2021).

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  • Constipation
  • Urinary tract infections
  • Abdominal radiograph