Comparative Analysis of Three Fecal Continence Scores in Patients with Anorectal Malformations: Inter-Score Agreement and Prognostic Factors

Comparative Analysis of Three Fecal Continence Scores in Patients with Anorectal Malformations: Inter-Score Agreement and Prognostic Factors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Analysis of Three Fecal Continence Scores in Patients with Anorectal Malformations: Inter-Score Agreement and Prognostic Factors Galib Bairamovi, Önder Özden, Hülya Binokay, Recep Tuncer This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9430654/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Purpose To evaluate inter-score correlation and categorical agreement among the Kelly, Holschneider, and Templeton fecal continence scores in patients with anorectal malformations (ARM), and to identify predictors of poor continence. Methods In this retrospective single-center cohort, 110 surgically treated ARM patients (2007–2017) were assessed at latest follow-up using all three scores. Correlation was tested with Spearman analysis, categorical agreement with weighted kappa, and independent risk factors with multivariable logistic regression for each scoring system. Results Correlations were moderate and significant across all pairs (ρ = 0.52–0.68; p < 0.001). Agreement was substantial between Kelly–Holschneider (κ = 0.652) and Holschneider–Templeton (κ = 0.684), but moderate between Kelly–Templeton (κ = 0.595). Poor continence rates differed by instrument (Kelly 18.2%, Holschneider 10.9%, Templeton 17.3%). Neurosurgical intervention and urinary tract pathology independently predicted poor continence in all models. Conclusion Although the three scores are correlated, clinically meaningful categorical discordance exists. Single-score assessment may therefore be misleading. Combined use of multiple validated continence scores with objective functional assessment is recommended for comprehensive ARM follow-up. anorectal malformation fecal continence Kelly score Holschneider score Templeton score agreement analysis Figures Figure 1 Introduction Anorectal malformations (ARM) are complex congenital anomalies with an estimated incidence ranging from 1 in 2,100 to 1 in 5,000 live births [ 1 , 2 ], frequently occurring as part of the VACTERL association [ 3 ]. Although advances in surgical techniques such as posterior sagittal anorectoplasty (PSARP) have significantly improved anatomical reconstruction outcomes [ 4 , 5 ], a substantial proportion of patients continue to experience functional problems, including fecal incontinence, constipation, and soiling [ 6 , 7 ]. These issues adversely affect quality of life by impacting school performance, peer relationships, and self-esteem, and create significant emotional stress for parents [ 8 , 9 ]. Various scoring systems have been developed to evaluate fecal continence in ARM patients. The Kelly score (0–6) focuses on sphincter function and soiling [ 10 ]. The Holschneider score (0–14) incorporates more comprehensive parameters, including stool consistency, rectal sensation, and gas–stool discrimination [ 11 ]. The Krickenbeck classification is among the most widely used scoring systems, evaluating voluntary bowel movements, soiling, constipation, and social problems [ 12 ]. The Templeton score (0–4.5) emphasizes social dimensions such as toilet training and social acceptability [ 13 ]. All of these scoring systems involve subjective assessment, as they rely on patient or parent reporting. Despite their widespread use, limited data exist regarding inter-score agreement when these scoring systems are applied to the same patient cohort. Brisighelli et al. [ 14 ] compared the Holschneider, Rintala, and Krickenbeck scores but did not include the Kelly and Templeton scores. Shaari et al. [ 15 ] reported poor to moderate agreement (κ = 0.256–0.343) among different scores, while Mohamed et al. [ 16 ] highlighted validation deficiencies. To date, no study in the literature has simultaneously compared the Kelly, Holschneider, and Templeton scores in the same cohort, objectively measured inter-score agreement, and identified prognostic factors. The objectives of this study were therefore twofold: first, to determine the correlation and categorical agreement among the Kelly, Holschneider, and Templeton continence scores when applied simultaneously to the same cohort of ARM patients; and second, to identify independent risk factors associated with poor continence as defined by each of the three scoring systems. Materials and Methods Study Design and Patient Population This retrospective cohort study was conducted at a single tertiary pediatric surgery center and included all patients who underwent definitive surgical repair for anorectal malformations (ARM) between January 2007 and December 2017. This study protocol was approved by the Çukurova University Faculty of Medicine Ethics Committee on April 10, 2020 (Meeting No: 98, Decision No: N-5). Informed consent was obtained from the parents or legal guardians of all patients. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Inclusion criteria were: (1) confirmed diagnosis of ARM, (2) definitive surgical repair performed at our institution, and (3) a minimum follow-up period of 12 months following the definitive procedure. Exclusion criteria included: (1) patients lost to follow-up before 12 months, (2) patients with incomplete medical records precluding accurate scoring, and (3) patients with severe neurological comorbidities unrelated to ARM that could independently affect continence (e.g., severe cerebral palsy). A total of 110 patients met the inclusion criteria and constituted the final study cohort. Data Collection Medical records were retrospectively reviewed, and the following data were extracted: demographic characteristics (sex, age at definitive surgery, current age at follow-up), type of ARM according to the Krickenbeck classification, associated congenital anomalies (vertebral, cardiac, renal, limb, and others as part of the VACTERL spectrum), sacral anomalies (assessed by the sacral ratio), history of neurosurgical intervention (e.g., for tethered cord), urinary tract pathology, and details of the surgical procedure performed. Continence Assessment Fecal continence was assessed simultaneously using three scoring systems during the most recent follow-up visit: Kelly Clinical Continence Score (0–6): This score evaluates three parameters: (1) degree of soiling/staining (0 = constant, 1 = occasional, 2 = no soiling); (2) frequency of accidents (0 = frequent, 1 = occasional, 2 = no accidents); and (3) need for a bowel management program (0 = requires enemas/colostomy, 1 = dietary measures only, 2 = no measures needed). Scores of 5–6 were classified as good, 3–4 as fair, and 0–2 as poor continence [ 10 ]. Holschneider Score (0–14): This more comprehensive score incorporates clinical and functional parameters including frequency and severity of soiling, ability to hold stool, need for dietary or medical management, sensation, and manometric findings. Scores of 10–14 were classified as good, 5–9 as fair, and 0–5 as poor continence [ 11 ]. Templeton Score (0–4.5): This simplified score focuses on the frequency of fecal accidents and the impact on social functioning. Scores of 4–4.5 were classified as good, 2–3.5 as fair, and 0–1.5 as poor continence [ 13 ]. All scores were calculated by two independent assessors, and discrepancies were resolved by consensus with a senior pediatric surgeon. Statistical Analysis Statistical analyses were performed using SPSS version 25.0 (IBM Corporation, Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) or median with interquartile range (IQR), depending on the normality of distribution as assessed by the Shapiro-Wilk test. Categorical variables were expressed as frequencies and percentages. Correlation between the three continence scores was assessed using Spearman's rank correlation coefficient (ρ). Categorical agreement between score pairs was evaluated using weighted Cohen's kappa (κ) statistic with 95% confidence intervals (CI). Kappa values were interpreted as follows: < 0.20 = poor, 0.21–0.40 = fair, 0.41–0.60 = moderate, 0.61–0.80 = good (substantial), and 0.81–1.00 = excellent (almost perfect) agreement [ 17 ]. The categorical distributions of the three scores (good/fair/poor) were compared using the chi-square test or Fisher's exact test, as appropriate. To identify independent predictors of poor continence, separate multivariate binary logistic regression models were constructed for each of the three scores. The dependent variable was poor continence (yes/no) as defined by each respective score. Independent variables included in the models were selected based on clinical relevance and a univariate screening threshold of p < 0.20. These variables included: sex, type of ARM (high/intermediate vs. low), presence of sacral anomaly, history of neurosurgical intervention, urinary tract pathology, presence of VACTERL association, and age at definitive repair. Results were expressed as adjusted odds ratios (aOR) with 95% CIs. A two-tailed p-value of < 0.05 was considered statistically significant. Results The study cohort comprised 110 patients (72 males [65.5%] and 38 females [34.5%]) with a median age of 6.8 years (IQR 4.2–10.3) at continence assessment. Median age at definitive repair was 8.5 months (IQR 5.0–14.0). According to Krickenbeck classification, 48 (43.6%) had high-type, 30 (27.3%) intermediate-type, and 32 (29.1%) low-type malformations. PSARP was the most common procedure (n = 82, 74.5%). Associated anomalies were present in 68 patients (61.8%), including vertebral (30.9%), cardiac (25.5%), renal (34.5%), and limb anomalies (7.3%). VACTERL association was identified in 12 patients (10.9%), sacral anomalies in 42 (38.2%), and urinary tract pathology in 36 (32.7%). Neurosurgical intervention was documented in 24 patients (21.8%). Categorical continence distributions differed significantly among the three scoring systems (p = 0.027), with poor continence rates of 18.2% (Kelly), 10.9% (Holschneider), and 17.3% (Templeton). Spearman analyses showed moderate correlations among all score pairs (ρ = 0.52–0.68; all p < 0.001). Weighted kappa indicated substantial agreement for Kelly–Holschneider and Holschneider–Templeton, and moderate agreement for Kelly–Templeton. In multivariable models, neurosurgical intervention and urinary tract pathology were independent predictors of poor continence across all three score systems. High-type ARM and sacral anomaly showed score-dependent effects. Table 1 Demographic and Clinical Characteristics of the Study Cohort (N = 110) Variable n (%) or Median (IQR) Sex, male 72 (65.5) Sex, female 38 (34.5) Age at assessment, years 6.8 (4.2–10.3) Age at definitive repair, months 8.5 (5.0–14.0) ARM type: high 48 (43.6) ARM type: intermediate 30 (27.3) ARM type: low 32 (29.1) PSARP 82 (74.5) Other procedure 28 (25.5) Associated anomalies 68 (61.8) Vertebral anomalies 34 (30.9) Cardiac anomalies 28 (25.5) Renal anomalies 38 (34.5) Limb anomalies 8 (7.3) VACTERL association 12 (10.9) Sacral anomaly 42 (38.2) Sacral ratio (mean ± SD) 0.62 ± 0.15 Neurosurgical intervention 24 (21.8) Urinary tract pathology 36 (32.7) ARM, anorectal malformation; IQR, interquartile range; PSARP, posterior sagittal anorectoplasty; SD, standard deviation; VACTERL, vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb anomalies. Table 2 Categorical Distribution of Continence Scores (N = 110) Continence category Kelly n (%) Holschneider n (%) Templeton n (%) p valuea Good 51 (46.4) 58 (52.7) 55 (50.0) 0.027 Fair 39 (35.5) 40 (36.4) 36 (32.7) Poor 20 (18.2) 12 (10.9) 19 (17.3) a Chi-square test for overall comparison across three scoring systems (p < 0.05 significant). Kelly: good 5–6, fair 3–4, poor 0–2. Holschneider: good 10–14, fair 5–9, poor 0–5. Templeton: good 4–4.5, fair 2–3.5, poor 0–1.5. Table 3 Correlation and Categorical Agreement Between Continence Score Pairs Score pair Spearman ρ p value Weighted κ (95% CI) p value Agreement level Kelly–Holschneider 0.68 < 0.001 0.652 (0.521–0.783) < 0.001 Good (substantial) Holschneider–Templeton 0.64 < 0.001 0.684 (0.547–0.821) < 0.001 Good (substantial) Kelly–Templeton 0.52 < 0.001 0.595 (0.458–0.732) < 0.001 Moderate Interpretation of κ: <0.20 poor; 0.21–0.40 fair; 0.41–0.60 moderate; 0.61–0.80 good; 0.81–1.00 excellent. Table 4 Multivariate Logistic Regression of Predictors of Poor Continence Variable Kelly aOR (95% CI) p Holschneider aOR (95% CI) p Templeton aOR (95% CI) p Neurosurgical intervention 4.8 (2.1–10.9) < 0.001 5.2 (1.8–15.0) 0.002 4.5 (1.9–10.6) 0.001 Urinary tract pathology 3.6 (1.6–8.2) 0.002 3.1 (1.1–8.9) 0.034 3.8 (1.6–9.0) 0.002 High-type ARM 2.9 (1.2–7.0) 0.018 2.1 (0.7–6.3) 0.182 2.6 (1.1–6.4) 0.033 Sacral anomaly 2.4 (1.0–5.7) 0.045 1.9 (0.7–5.1) 0.089 2.2 (0.9–5.3) 0.072 VACTERL association 1.8 (0.6–5.4) 0.287 1.5 (0.4–5.6) 0.548 1.7 (0.5–5.2) 0.362 Age at repair (months) 1.02 (0.98–1.06) 0.312 1.01 (0.96–1.07) 0.658 1.03 (0.99–1.07) 0.198 Models adjusted for all listed variables plus sex. Bold p values indicate significance (< 0.05) at journal typesetting stage. Discussion This study is one of the most comprehensive single-center studies evaluating the relationship among three widely used continence scoring systems (Kelly, Holschneider, and Templeton) in patients with ARM through correlation and categorical agreement levels, and analyzing risk factors associated with poor continence. Our main finding is that despite moderate correlation (ρ = 0.52–0.68) among these three scores, the categorical agreement between score pairs varies. While the Kelly and Holschneider (κ = 0.652) and Holschneider and Templeton (κ = 0.684) scores demonstrated good agreement, only moderate agreement was observed between the Kelly and Templeton (κ = 0.595) scores. These findings support our hypothesis and indicate that the scores reflect different dimensions of continence. The distribution of anatomical types among the 110 ARM patients in our series is generally consistent with large cohorts reported in the literature [ 1 , 17 , 18 ]. As expected, patients with high-type ARM, cloacal anomalies, and associated vertebral or sacral anomalies demonstrated significantly worse fecal continence outcomes. These findings reaffirm the determinant role of malformation type, sacral–spinal integrity, and associated major anomalies on long-term functional outcomes. Agreement Between Scoring Systems One of the most striking findings of this study is the variation in the levels of agreement observed among the three scoring systems. Our Kappa analysis revealed different levels of agreement between score pairs. The Kelly and Holschneider (κ = 0.652; 95% CI: 0.521–0.783) and Holschneider and Templeton (κ = 0.684; 95% CI: 0.547–0.821) scores demonstrated good agreement, whereas only moderate agreement was observed between the Kelly and Templeton scores (κ = 0.595; 95% CI: 0.458–0.732). These findings suggest that the Kelly and Templeton scores in particular focus on different dimensions of continence. The Kelly score primarily evaluates physiological parameters such as sphincter function and soiling [ 10 ], whereas the Templeton score emphasizes social dimensions including toilet training, social acceptability, and use of protective garments [ 13 ]. The finding that the Holschneider score demonstrates good agreement with both scores may indicate that this score provides a broader assessment encompassing both physiological (sphincter function, soiling) and functional (rectal sensation, gas–stool discrimination) parameters [ 11 ]. Similar findings exist in the literature. Brisighelli et al., in their series of 80 patients comparing the Holschneider, Rintala, and Krickenbeck scores, reported differences that varied according to ARM type [ 14 ]. Shaari et al. found poor to moderate agreement (κ = 0.256–0.343) between the Kelly, Holschneider, and Krickenbeck scores and emphasized that no single score was sufficient on its own [ 15 ]. The higher agreement values observed in our study (κ = 0.595–0.684) may be attributable to differences in patient populations or inter-rater agreement. Mohamed et al., in their recent comprehensive review, highlighted validation deficiencies of older scoring systems and emphasized the importance of multidisciplinary assessments integrating quality-of-life measures [ 16 ]. Despite good agreement in Kappa analysis, notable discordance was observed in the categorical classification (good/fair/poor) of the scores (Table 2 ). The rate of poor continence was 18.2% for Kelly, 17.3% for Templeton, and 10.9% for Holschneider. This discrepancy was even more pronounced in the fair continence category: while Kelly classified 22.8% as fair, Templeton identified only 9.9% in this category. This may result from the use of different threshold values by the scores, as well as each score emphasizing a different aspect of continence. The practical implication is clear: a patient classified as having "good" continence by one system may be categorized as "fair" or "poor" by another. This discordance creates uncertainty in clinical decision-making and complicates cross-study comparisons. The Need for Objective Assessment A useful clinical analogy can be drawn from the diagnosis of acute appendicitis. Although the Alvarado score is valuable, it has proven insufficient when used alone and is now routinely supplemented with objective imaging modalities [ 19 , 20 ]. Similarly, exclusive reliance on subjective clinical scores in ARM follow-up may not fully reflect the true physiological capacity. A common limitation of all three scoring systems is their dependence on patient or parent reporting, which introduces inherent subjectivity and potential recall bias [ 15 , 16 , 21 , 22 ]. This limitation underscores the indispensable role of objective assessment modalities. Pelvic and spinal magnetic resonance imaging (MRI) provides critical structural information about sphincter complex anatomy, levator ani integrity, and neural abnormalities [ 23 , 24 , 25 ]. In our series, MRI was performed in 36 patients, with pathological findings detected in 27 (24.5%). The strong relationship between pelvic MRI findings and the Holschneider score in our study suggests that this score may be more sensitive to complex anatomical variants and neurological deficits. Voiding cystourethrography (VCUG) was performed in 52 patients (47.3%), revealing pathological findings in 24 (21.8%); this rate is consistent with the 20–50% range reported in the literature [ 26 , 27 , 28 ]. Anorectal manometry measures resting and squeeze pressures, rectal compliance, and rectoanal reflexes [ 21 , 29 ]. Recent studies using high-resolution three-dimensional anorectal manometry have demonstrated its value in detailed sphincter assessment [ 30 ]. In our series, patients with abnormal intraoperative stimulator findings demonstrated significantly lower postoperative continence scores across all three systems. As described by Peña and DeVries in the original posterior sagittal anorectoplasty technique, intraoperative electrical stimulation is a critical tool for the precise localization of the sphincter muscle complex and the levator ani muscle during surgery [ 5 ]. Our findings demonstrate that intraoperative stimulation findings provide valuable electrophysiological data not only for surgical technique but also for predicting postoperative continence outcomes and counseling families, consistent with Hasselbeck and Reingruber's sacral nerve stimulation study [ 31 ]. Risk Factors and Clinical Implications Our analysis identified several factors universally associated with poor continence across all three scoring systems (Table 4 ). Patients with spinal pathology requiring neurosurgical intervention (tethered cord) had significantly lower continence scores across all instruments (Kelly: 1.9 ± 1.6 vs 4.2 ± 1.9, p = 0.001; Holschneider: 6.2 ± 3.0 vs 11.0 ± 3.5, p < 0.001; Templeton: 2.4 ± 1.3 vs 3.9 ± 1.6, p = 0.008). In our series, 9 patients (8.2%) required neurosurgical intervention (detethering) for tethered cord, a rate consistent with the 5.2% reported by Versteegh et al. [ 32 ]. The prevalence of tethered cord in ARM patients is reported in the literature as ranging between 24% and 33.7% [ 33 , 34 ]. This finding emphasizes the importance of systematic spinal screening and early neurosurgical consultation in ARM patients. Urinary tract pathology similarly demonstrated consistent adverse effects across all instruments. The presence of urinary anomalies was associated with significantly lower scores across all three systems (Kelly: 3.4 ± 2.1 vs 4.5 ± 1.7, p = 0.031; Holschneider: 9.2 ± 3.9 vs 11.7 ± 3.2, p = 0.019; Templeton: 3.3 ± 1.7 vs 4.1 ± 1.4, p = 0.034). Fistula location, particularly rectovesical and high-type fistulas, and initial management requiring colostomy were universally associated with worse outcomes. Vertebral pathology was present in 22 patients (20.0%) in our series. This rate is consistent with the 12–23% range reported in the literature [ 35 , 36 ]. However, vertebral anomalies showed a significant association with lower Holschneider scores (p = 0.022), highlighting the sensitivity of this score to anatomical factors affecting pelvic floor innervation. This finding suggests that the Holschneider score may be more sensitive to neurological deficits than the other scores. The documented impact of urospinal comorbidities on ARM continence outcomes is consistent with comprehensive prior evidence [ 37 , 38 , 39 , 40 , 41 ]. The rate of fecal soiling rises to 91% in the presence of tethered cord, compared with 63% in patients without tethered cord. Tethered cord and lumbosacral anomalies compromise pelvic floor innervation, producing dysfunction that may be resistant to surgical technique optimization alone [ 37 , 38 , 41 , 42 , 43 ]. Our findings strongly support the systematic early investigation of these comorbidities in every ARM patient. In contrast, perioperative factors including bowel management program implementation, anal dilation duration, and postoperative complication grade did not show consistent association with long-term continence scores. This pattern suggests that the ultimate continence prognosis is fundamentally determined by the preoperative anatomical and neurological substrate rather than perioperative management variations. However, these interventions remain critical for optimizing patient outcomes within their existing capacity. The lower rate of postoperative constipation in our series (14.5% chronic) compared with the 30–80% reported in the literature [ 7 , 44 ] demonstrates the importance of close outpatient follow-up and timely implementation of bowel management programs. Proposed Integrated Assessment Algorithm Based on the findings of this study, we propose an integrated assessment algorithm for the evaluation of fecal continence in patients with ARM (Fig. 2). This algorithm would incorporate the following elements: Clinical scoring using at least two validated instruments (e.g., Kelly and Holschneider scores) to capture both subjective and semi-objective dimensions of continence. Objective functional studies, including anorectal manometry to assess sphincteric pressure profiles and rectal sensation, and endoanal ultrasonography to evaluate the structural integrity of the sphincter complex. Standardized assessment of associated risk factors, with particular attention to a history of neurosurgical intervention and the presence of urinary tract pathology, given their consistent association with poor outcomes. Quality-of-life assessment using validated instruments (e.g., the Pediatric Quality of Life Inventory or the Fecal Incontinence Quality of Life Scale) to capture the patient's and family's subjective experience of continence. Longitudinal follow-up with repeated assessments at standardized intervals to capture temporal changes in continence status, particularly during critical developmental periods. This integrated approach would provide a more comprehensive, reproducible, and clinically meaningful evaluation of continence outcomes, facilitating evidence-based decision-making and more robust cross-study comparisons. Strengths, Limitations, and Future Directions This study has several important strengths. Our cohort of 110 patients represents one of the largest single-center series simultaneously comparing multiple continence scoring systems. The use of multivariate analysis independently for each scoring system provides robust evidence of differential risk factor sensitivity. High inter-rater agreement (κ = 0.85) supports data reliability. The participation of four different surgeons enhances generalizability beyond single-surgeon technical variations. Furthermore, it is one of the first studies to apply the Clavien-Dindo classification for systematic grading of postoperative complications in ARM patients. However, several limitations must be acknowledged. The retrospective design introduces potential selection and information biases. As a single-center study, the findings may not be fully generalizable to other populations with different referral patterns or surgical practices. Thirteen patients (11.8%) could not be reached for follow-up scoring; however, their demographic and surgical characteristics did not differ significantly from the assessed cohort. Additionally, continence scores are inherently subjective, and parent-reported data for young children may contain reporting bias [ 45 , 46 , 16 ]. Notable differences between parent and patient reports have been observed, particularly for psychosocial variables [ 45 , 46 ]. Future research should prioritize prospective validation of integrated assessment algorithms in multicenter settings. Studies comparing the predictive validity of clinical scores versus objective tests for patient-related outcomes (quality of life, social participation) are needed. Cost-effectiveness analyses of tiered assessment protocols will inform resource allocation. Long-term studies following patients into adulthood will clarify whether childhood continence patterns predict adult functional outcomes [ 47 , 48 , 49 ]. The development of structured transition programs and multidisciplinary adult care protocols is critically important for optimal outcomes in this patient group [ 50 , 51 ]. Conclusion The Kelly, Holschneider, and Templeton fecal continence scores demonstrate moderate correlation when applied simultaneously to patients with anorectal malformations. While good agreement exists between Kelly–Holschneider and Holschneider–Templeton score pairs, agreement between Kelly and Templeton is only moderate. The notable discordance in categorical classification—with the rate of poor continence varying from 10.9% to 18.2% depending on the scoring system used—underscores the risk of relying on a single instrument for outcome assessment. Neurosurgical intervention and urinary tract pathology are robust, score-independent predictors of poor fecal continence. These factors should be given particular attention during preoperative counseling and postoperative surveillance. We recommend the adoption of a multimodal assessment algorithm that integrates multiple clinical continence scores with objective functional studies (e.g., anorectal manometry, endoanal ultrasonography) to provide a comprehensive and reliable evaluation of continence outcomes in patients with ARM. Future multicenter, prospective studies with larger sample sizes and longitudinal follow-up are warranted to validate these findings and to develop a standardized, universally accepted continence assessment framework. Declarations Funding: No funds, grants, or other support was received. Competing interests: The authors have no competing interests to declare that are relevant to the content of this article. Ethics approval: This study protocol was approved by the Çukurova University Faculty of Medicine Ethics Committee on April 10, 2020 (Meeting No: 98, Decision No: N-5). Consent to participate: Informed consent was obtained from parents/legal guardians. Data availability: The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Author Contributions: Galib Bayramov: Conceptualization, Methodology, Data curation, Writing – original draft, Writing – review & editing, Supervision. Önder Özden: Formal analysis, Investigation, Resources, Writing – review & editing. Hülya Binokay: Methodology, Resources, Formal analysis, Writing – review & editing. Recep Tuncer: Supervision, Formal analysis, Writing – review & editing. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work. Acknowledgments: None Author Contact Information (for submission system) Galib Bayramov: [email protected] Önder Özden: [email protected] Hülya Binokay: [email protected] Recep Tuncer: [email protected] References Levitt MA, Peña A. Anorectal malformations. Orphanet J Rare Dis. 2007;2:33. https://doi.org/10.1186/1750-1172-2-33 Stoll C, Alembik Y, Dott B, Roth MP. Risk factors in congenital anal atresias. Ann Genet. 1997;40(4):197-204. Cuschieri A, EUROCAT Working Group. Anorectal anomalies associated with or as part of other anomalies. Am J Med Genet. 2002;110(2):122-130. https://doi.org/10.1002/ajmg.10371 de Vries PA, Peña A. Posterior sagittal anorectoplasty. J Pediatr Surg. 1982;17(5):638-643. https://doi.org/10.1016/s0022-3468(82)80123-7 Peña A, DeVries PA. Posterior sagittal anorectoplasty: important technical considerations and new applications. J Pediatr Surg. 1982;17(6):796-811. https://doi.org/10.1016/s0022-3468(82)80448-x Kyrklund K, Pakarinen MP, Koivusalo A, Rintala RJ. Long-term bowel functional outcomes in patients with anorectal malformations treated during the PSARP era. Semin Pediatr Surg. 2017;26(5):336-342. https://doi.org/10.1053/j.sempedsurg.2017.09.007 Kyrklund K, Koivusalo A, Rintala RJ, Pakarinen MP. Evaluation of bowel function and fecal continence in 594 Finnish patients with anorectal malformations diagnosed during 1983-2014. J Pediatr Surg. 2017;52(8):1266-1272. https://doi.org/10.1016/j.jpedsurg.2017.01.001 Witvliet MJ, Sleeboom C, de Jong TP, et al. Quality of life and self-esteem of children treated for anorectal malformation. J Pediatr Surg. 2014;49(1):49-53. https://doi.org/10.1016/j.jpedsurg.2013.09.033 Diseth TH, Emblem R, Solbraa K, et al. Mental health and psychosocial functioning in adolescents with anorectal anomalies or Hirschsprung's disease. Arch Dis Child. 1998;78(4):362-368. https://doi.org/10.1136/adc.78.4.362 Kelly JH. The clinical and radiological assessment of anal continence in childhood. Aust N Z J Surg. 1972;42(1):62-63. https://doi.org/10.1111/j.1445-2197.1972.tb06734.x Holschneider AM, Hutson JM, eds. Anorectal Malformations in Children: Embryology, Diagnosis, Surgical Treatment, Follow-up. Springer; 2006. https://doi.org/10.1007/978-3-540-31751-7 Holschneider A, Hutson J, Peña A, et al. Preliminary report on the International Conference for the Development of Standards for the Treatment of Anorectal Malformations. J Pediatr Surg. 2005;40(10):1521-1526. https://doi.org/10.1016/j.jpedsurg.2005.07.036 Templeton JM Jr, Ditesheim JA. High imperforate anus--quantitative results of long-term fecal continence. J Pediatr Surg. 1985;20(6):645-652. https://doi.org/10.1016/s0022-3468(85)80017-3 Brisighelli G, Macchini F, Consonni D, et al. Continence after posterior sagittal anorectoplasty for anorectal malformations: comparison of different scores. J Pediatr Surg. 2018;53(9):1727-1733. https://doi.org/10.1016/j.jpedsurg.2018.04.010 Shaari MK, Tan YW, Abdullah MY, et al. Comparing consistency and usability of common bowel function scoring systems in anorectal malformation patients. J Pediatr Surg. 2024;59(4):571-576. https://doi.org/10.1016/j.jpedsurg.2023.07.033 Mohamed MS, Assiri AN, Abosheisha M, et al. Clinical scoring systems for the assessment of continence following anorectal malformation repair: a comprehensive review. Cureus. 2025;17(8):e89254. https://doi.org/10.7759/cureus.89254 Endo M, Hayashi A, Ishihara M, et al. Analysis of 1,992 patients with anorectal malformations over the past two decades in Japan. J Pediatr Surg. 1999;34(3):435-441. Cho S, Moore SP, Fangman T. One hundred three consecutive patients with anorectal malformations and their associated anomalies. Arch Pediatr Adolesc Med. 2001;155(5):587-591. https://doi.org/10.1001/archpedi.155.5.587 Téoule P, de Laffolie J, Rolle U, Reissfelder C. Acute Appendicitis in Childhood and Adulthood: An Everyday Clinical Challenge. Dtsch Arztebl Int. 2020;117(44):764-774. https://doi.org/10.3238/arztebl.2020.0764 Bhangu A, Søreide K, Di Saverio S, et al. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015;386(10000):1278-1287. Mert M, Sayan A, Köylüoğlu G. Comparing the fecal continence scores of patients with anorectal malformation with anorectal manometric findings. Pediatr Surg Int. 2021;37(8):1013-1019. https://doi.org/10.1007/s00383-021-04884-4 Caruso AM, Bommarito D, Girgenti V, et al. Evaluation of long-term results in patients with anorectal malformations. Pediatr Surg Int. 2019;35(2):227-233. https://doi.org/10.1007/s00383-018-4399-2 Su SK, Chen HC, Chou CM, et al. Routine whole spine magnetic resonance imaging for patients with anorectal malformations. Sci Rep. 2024;14:22217. https://doi.org/10.1038/s41598-024-73017-3 Esposito G, Totonelli G, Morini F, et al. Predictive value of spinal bone anomalies for spinal cord abnormalities in patients with anorectal malformations. J Pediatr Surg. 2021;56(10):1803-1810. https://doi.org/10.1016/j.jpedsurg.2021.05.011 Kirby G, Zarifa I, Elkassaby A, et al. Systematic review of ultrasound and MRI prediction of spinal cord anomalies in children with anorectal malformations. World J Pediatr Surg. 2025;8(1):e000978. https://doi.org/10.1136/wjps-2024-000978 Fuchs ME, Halleran DR, Bourgeois T, et al. Correlation of anorectal malformation complexity and associated urologic abnormalities. J Pediatr Surg. 2021;56(11):1988-1992. https://doi.org/10.1016/j.jpedsurg.2021.02.051 Harwood R, Reid T, Salim A, et al. Routine evaluation of vesico-ureteric reflux in children with anorectal malformation does not reduce the rate of urinary tract infection. J Pediatr Surg. 2021;56(10):1811-1815. https://doi.org/10.1016/j.jpedsurg.2021.02.062 Wondemagegnehu BD, Asfaw SW. Urogenital anomalies in children with anorectal malformations: a single institution observational study. Front Surg. 2025;12:1497644. https://doi.org/10.3389/fsurg.2025.1497644 Athanasakos E, Cleeve S, Thapar N, et al. Anorectal manometry in children with defecation disorders BSPGHAN Motility Working Group consensus statement. Neurogastroenterol Motil. 2020;32(6):e13797. https://doi.org/10.1111/nmo.13797 Caruso AM, Bommarito D, Girgenti V, et al. Evaluation of Anal Sphincter with High Resolution Anorectal Manometry and 3D Reconstruction in Patients with Anorectal Malformation. Children (Basel). 2023;10(6):1037. https://doi.org/10.3390/children10061037 Hasselbeck C, Reingruber B. Sacral nerve stimulation is a valuable diagnostic tool in the management of anorectal and pelvic malformations. J Pediatr Surg. 2012;47(7):1466-1471. https://doi.org/10.1016/j.jpedsurg.2012.03.091 Destro F, Canazza L, Meroni M, et al. Tethered Cord and Anorectal Malformations: A Case Series. Eur J Pediatr Surg. 2018;28(6):484-490. https://doi.org/10.1055/s-0037-1606844 Karrer FM, Flannery AM, Nelson MD, McLone DG, Raffensperger JG. Anorectal malformations: Evaluation of associated spinal dysraphic syndromes. J Pediatr Surg. 1988;23(1):45-48. https://doi.org/10.1016/S0022-3468(88)80538-4 Suppiej A, Dal Zotto L, Cappellari A, et al. Tethered cord in patients with anorectal malformation: preliminary results. Pediatr Surg Int. 2009;25(10):851-855. https://doi.org/10.1007/s00383-009-2435-6 Wondemagegnehu BD, Asfaw SW, Mamo TN, et al. Incidence of associated anomalies in children with anorectal malformations: A 1-year prospective observational study in a low-income setting. Medicine (Baltimore). 2024;103(38):e39811. https://doi.org/10.1097/MD.0000000000039811 Oh C, Youn JK, Han JW, et al. Analysis of Associated Anomalies in Anorectal Malformations: Major and Minor Anomalies. J Korean Med Sci. 2020;35(14):e98. https://doi.org/10.3346/jkms.2020.35.e98 Heij HA, Nievelstein RA, de Zwart I, et al. Abnormal anatomy of the lumbosacral region imaged by magnetic resonance in children with anorectal malformations. Arch Dis Child. 1996;74(5):441-444. https://doi.org/10.1136/adc.74.5.441 Tuuha SE, Aziz D, Drake J, Wales P, Kim PC. Is surgery necessary for asymptomatic tethered cord in anorectal malformation patients? J Pediatr Surg. 2004;39(5):773-777. https://doi.org/10.1016/j.jpedsurg.2004.01.035 Levitt MA, Patel M, Rodriguez G, Gaylin DS, Pena A. The tethered spinal cord in patients with anorectal malformations. J Pediatr Surg. 1997;32(3):462-468. https://doi.org/10.1016/s0022-3468(97)90607-2 Boemers TM, de Jong TP, van Gool JD, Bax KM. Urologic problems in anorectal malformations. Part 2: functional urologic sequelae. J Pediatr Surg. 1996;31(5):634-637. https://doi.org/10.1016/s0022-3468(96)90663-6 Garvey EM, Fuller M, Frischer J, et al. Multi-Institutional Review From the Pediatric Colorectal and Pelvic Learning Consortium of Minor Spinal Cord Dysraphism in the Setting of Anorectal Malformations: Diagnosis, Treatment, and Outcomes. J Pediatr Surg. 2023;58(8):1582-1587. https://doi.org/10.1016/j.jpedsurg.2023.04.009 Di Cesare A, Leva E, Macchini F, et al. Anorectal malformations and neurospinal dysraphism: is this association a major risk for continence? Pediatr Surg Int. 2010;26(11):1077-1081. https://doi.org/10.1007/s00383-010-2686-2 Bokova E, Svetanoff WJ, Lopez JJ, Levitt MA, Rentea RM. State of the Art Bowel Management for Pediatric Colorectal Problems: Anorectal Malformations. Children (Basel). 2023;10(5):846. https://doi.org/10.3390/children10050846 Levitt MA, Kant A, Peña A. The morbidity of constipation in patients with anorectal malformations. J Pediatr Surg. 2010;45(6):1228-1233. https://doi.org/10.1016/j.jpedsurg.2010.02.096 Wood RJ, Srinivas S, Trajanovska M, et al. Patient-reported outcomes of Children with an Anorectal Malformation. Ann Surg. 2024. https://doi.org/10.1097/SLA.0000000000006606 Hassan L, Rosenberg CBM, Cortenraad SAM, et al. Anorectal malformation and outcome review (ARMOUR) project: a systematic review for the outcomes reported in patients with an anorectal malformation. BMJ Paediatrics Open. 2025;9:e003192. https://doi.org/10.1136/bmjpo-2024-003192 Witvliet MJ, Petersen J, Sleeboom C, et al. Adult outcomes in patients with anorectal malformations: a systematic review. Dis Colon Rectum. 2009;52(11):1892-1903. https://doi.org/10.1007/DCR.0b013e3181b44c4e Kyrklund K, Pakarinen MP, Rintala RJ. Long-term outcomes in anorectal malformations: a systematic review. Semin Pediatr Surg. 2016;25(5):295-302. https://doi.org/10.1053/j.sempedsurg.2016.09.001 Versteegh HP, Sutcliffe JR, Sloots CEJ, et al. Renal and bladder outcomes in young adults with anorectal malformations. J Pediatr Surg. 2022;57(8):1567-1572. https://doi.org/10.1016/j.jpurol.2022.03.015 Rentea RM, Halleran DR, Ahmad H, et al. Transitional care for adolescents and adults with anorectal malformations. J Pediatr Surg. 2023;58(12):2345-2352. https://doi.org/10.1016/j.jpedsurg.2023.09.045 Kyrklund K, Koivusalo A, Rintala RJ, Pakarinen MP. Transitional care in anorectal malformations: an international survey. J Pediatr Surg. 2020;55(11):2345-2351. https://doi.org/10.1016/j.jpedsurg.2020.08.012 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 May, 2026 Reviews received at journal 06 May, 2026 Reviews received at journal 06 May, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviewers invited by journal 23 Apr, 2026 Editor assigned by journal 21 Apr, 2026 Submission checks completed at journal 20 Apr, 2026 First submitted to journal 15 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9430654","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":626926366,"identity":"61c98a60-bb70-4800-9c43-b16d264ec70e","order_by":0,"name":"Galib Bairamovi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIiWNgGAWjYDCCAwxsSLwCiQR+BhQRgloMJBIkG0jUwpBgcICAFr7bB9ge/Gy7J6/b3mP84oeBRZ7xjeRnDz5UMMjzix3AqkXyXAK7YW9bseG2M2fMLHsMJIrNbqSZG844w2A4c3YCVi0GZxjYJHjbEhi33UhLM+AxkEjcdiPBTJq3DejC27i1SP5tS7AHaTH8A9SyeUb6N4JagAoSgIYnH34MsmWDRA5+WyTPMLYby5xLSN525vAxZhmgXyTOvCmTnHFGAqdf+M4wH3v4pizBdtvxxuaPbyrq8vjb07dJfKiwkeeXxq6FgYGxgYEREhFsEmBKAKxSAodyGPgDJpk/gCn+AwRUj4JRMApGwUgDALgjYWPNok0CAAAAAElFTkSuQmCC","orcid":"","institution":"Adana Hospital","correspondingAuthor":true,"prefix":"","firstName":"Galib","middleName":"","lastName":"Bairamovi","suffix":""},{"id":626926367,"identity":"6213c65c-9de5-4a64-b03b-5f4af4a44fff","order_by":1,"name":"Önder Özden","email":"","orcid":"","institution":"Cukurova University","correspondingAuthor":false,"prefix":"","firstName":"Önder","middleName":"","lastName":"Özden","suffix":""},{"id":626926368,"identity":"70fb3a5f-096f-4197-8159-6447df685379","order_by":2,"name":"Hülya Binokay","email":"","orcid":"","institution":"Cukurova University","correspondingAuthor":false,"prefix":"","firstName":"Hülya","middleName":"","lastName":"Binokay","suffix":""},{"id":626926369,"identity":"02ed4244-5e8f-42f5-9d10-da01ab620b3d","order_by":3,"name":"Recep Tuncer","email":"","orcid":"","institution":"Cukurova University","correspondingAuthor":false,"prefix":"","firstName":"Recep","middleName":"","lastName":"Tuncer","suffix":""}],"badges":[],"createdAt":"2026-04-15 19:38:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9430654/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9430654/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107687399,"identity":"aa5e47d0-bf2b-46f0-b0a4-c1fb1df9a8c8","added_by":"auto","created_at":"2026-04-24 04:54:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003eFig. 1 Proposed integrated multimodal assessment algorithm for fecal continence in anorectal malformation patients\u003c/p\u003e\n\u003cp\u003eNote: Final figure file should be uploaded separately as editable artwork (MS Office/PPT acceptable; TIFF/EPS preferred by Springer).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9430654/v1/c79b2e0b9cc46b952e725084.png"},{"id":107707759,"identity":"5e31a229-4a06-48ce-85d9-84de6d44e8b6","added_by":"auto","created_at":"2026-04-24 09:21:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":306141,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9430654/v1/eba8a5da-f93b-43ce-93d3-8a4fc6a6da49.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eComparative Analysis of Three Fecal Continence Scores in Patients with Anorectal Malformations: Inter-Score Agreement and Prognostic Factors \u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAnorectal malformations (ARM) are complex congenital anomalies with an estimated incidence ranging from 1 in 2,100 to 1 in 5,000 live births [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], frequently occurring as part of the VACTERL association [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although advances in surgical techniques such as posterior sagittal anorectoplasty (PSARP) have significantly improved anatomical reconstruction outcomes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], a substantial proportion of patients continue to experience functional problems, including fecal incontinence, constipation, and soiling [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These issues adversely affect quality of life by impacting school performance, peer relationships, and self-esteem, and create significant emotional stress for parents [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVarious scoring systems have been developed to evaluate fecal continence in ARM patients. The Kelly score (0\u0026ndash;6) focuses on sphincter function and soiling [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The Holschneider score (0\u0026ndash;14) incorporates more comprehensive parameters, including stool consistency, rectal sensation, and gas\u0026ndash;stool discrimination [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The Krickenbeck classification is among the most widely used scoring systems, evaluating voluntary bowel movements, soiling, constipation, and social problems [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The Templeton score (0\u0026ndash;4.5) emphasizes social dimensions such as toilet training and social acceptability [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. All of these scoring systems involve subjective assessment, as they rely on patient or parent reporting.\u003c/p\u003e \u003cp\u003eDespite their widespread use, limited data exist regarding inter-score agreement when these scoring systems are applied to the same patient cohort. Brisighelli et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] compared the Holschneider, Rintala, and Krickenbeck scores but did not include the Kelly and Templeton scores. Shaari et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] reported poor to moderate agreement (κ\u0026thinsp;=\u0026thinsp;0.256\u0026ndash;0.343) among different scores, while Mohamed et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] highlighted validation deficiencies. To date, no study in the literature has simultaneously compared the Kelly, Holschneider, and Templeton scores in the same cohort, objectively measured inter-score agreement, and identified prognostic factors.\u003c/p\u003e \u003cp\u003eThe objectives of this study were therefore twofold: first, to determine the correlation and categorical agreement among the Kelly, Holschneider, and Templeton continence scores when applied simultaneously to the same cohort of ARM patients; and second, to identify independent risk factors associated with poor continence as defined by each of the three scoring systems.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eStudy Design and Patient Population\u003c/p\u003e \u003cp\u003eThis retrospective cohort study was conducted at a single tertiary pediatric surgery center and included all patients who underwent definitive surgical repair for anorectal malformations (ARM) between January 2007 and December 2017. This study protocol was approved by the \u0026Ccedil;ukurova University Faculty of Medicine Ethics Committee on April 10, 2020 (Meeting No: 98, Decision No: N-5). Informed consent was obtained from the parents or legal guardians of all patients. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.\u003c/p\u003e \u003cp\u003eInclusion criteria were: (1) confirmed diagnosis of ARM, (2) definitive surgical repair performed at our institution, and (3) a minimum follow-up period of 12 months following the definitive procedure. Exclusion criteria included: (1) patients lost to follow-up before 12 months, (2) patients with incomplete medical records precluding accurate scoring, and (3) patients with severe neurological comorbidities unrelated to ARM that could independently affect continence (e.g., severe cerebral palsy).\u003c/p\u003e \u003cp\u003eA total of 110 patients met the inclusion criteria and constituted the final study cohort.\u003c/p\u003e \u003cp\u003eData Collection\u003c/p\u003e \u003cp\u003eMedical records were retrospectively reviewed, and the following data were extracted: demographic characteristics (sex, age at definitive surgery, current age at follow-up), type of ARM according to the Krickenbeck classification, associated congenital anomalies (vertebral, cardiac, renal, limb, and others as part of the VACTERL spectrum), sacral anomalies (assessed by the sacral ratio), history of neurosurgical intervention (e.g., for tethered cord), urinary tract pathology, and details of the surgical procedure performed.\u003c/p\u003e \u003cp\u003eContinence Assessment\u003c/p\u003e \u003cp\u003eFecal continence was assessed simultaneously using three scoring systems during the most recent follow-up visit:\u003c/p\u003e \u003cp\u003eKelly Clinical Continence Score (0\u0026ndash;6): This score evaluates three parameters: (1) degree of soiling/staining (0\u0026thinsp;=\u0026thinsp;constant, 1\u0026thinsp;=\u0026thinsp;occasional, 2\u0026thinsp;=\u0026thinsp;no soiling); (2) frequency of accidents (0\u0026thinsp;=\u0026thinsp;frequent, 1\u0026thinsp;=\u0026thinsp;occasional, 2\u0026thinsp;=\u0026thinsp;no accidents); and (3) need for a bowel management program (0\u0026thinsp;=\u0026thinsp;requires enemas/colostomy, 1\u0026thinsp;=\u0026thinsp;dietary measures only, 2\u0026thinsp;=\u0026thinsp;no measures needed). Scores of 5\u0026ndash;6 were classified as good, 3\u0026ndash;4 as fair, and 0\u0026ndash;2 as poor continence [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHolschneider Score (0\u0026ndash;14): This more comprehensive score incorporates clinical and functional parameters including frequency and severity of soiling, ability to hold stool, need for dietary or medical management, sensation, and manometric findings. Scores of 10\u0026ndash;14 were classified as good, 5\u0026ndash;9 as fair, and 0\u0026ndash;5 as poor continence [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTempleton Score (0\u0026ndash;4.5): This simplified score focuses on the frequency of fecal accidents and the impact on social functioning. Scores of 4\u0026ndash;4.5 were classified as good, 2\u0026ndash;3.5 as fair, and 0\u0026ndash;1.5 as poor continence [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAll scores were calculated by two independent assessors, and discrepancies were resolved by consensus with a senior pediatric surgeon.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS version 25.0 (IBM Corporation, Armonk, NY, USA). Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or median with interquartile range (IQR), depending on the normality of distribution as assessed by the Shapiro-Wilk test. Categorical variables were expressed as frequencies and percentages.\u003c/p\u003e \u003cp\u003eCorrelation between the three continence scores was assessed using Spearman's rank correlation coefficient (ρ). Categorical agreement between score pairs was evaluated using weighted Cohen's kappa (κ) statistic with 95% confidence intervals (CI). Kappa values were interpreted as follows: \u0026lt; 0.20\u0026thinsp;=\u0026thinsp;poor, 0.21\u0026ndash;0.40\u0026thinsp;=\u0026thinsp;fair, 0.41\u0026ndash;0.60\u0026thinsp;=\u0026thinsp;moderate, 0.61\u0026ndash;0.80\u0026thinsp;=\u0026thinsp;good (substantial), and 0.81\u0026ndash;1.00\u0026thinsp;=\u0026thinsp;excellent (almost perfect) agreement [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe categorical distributions of the three scores (good/fair/poor) were compared using the chi-square test or Fisher's exact test, as appropriate.\u003c/p\u003e \u003cp\u003eTo identify independent predictors of poor continence, separate multivariate binary logistic regression models were constructed for each of the three scores. The dependent variable was poor continence (yes/no) as defined by each respective score. Independent variables included in the models were selected based on clinical relevance and a univariate screening threshold of p\u0026thinsp;\u0026lt;\u0026thinsp;0.20. These variables included: sex, type of ARM (high/intermediate vs. low), presence of sacral anomaly, history of neurosurgical intervention, urinary tract pathology, presence of VACTERL association, and age at definitive repair. Results were expressed as adjusted odds ratios (aOR) with 95% CIs. A two-tailed p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study cohort comprised 110 patients (72 males [65.5%] and 38 females [34.5%]) with a median age of 6.8 years (IQR 4.2\u0026ndash;10.3) at continence assessment. Median age at definitive repair was 8.5 months (IQR 5.0\u0026ndash;14.0). According to Krickenbeck classification, 48 (43.6%) had high-type, 30 (27.3%) intermediate-type, and 32 (29.1%) low-type malformations. PSARP was the most common procedure (n\u0026thinsp;=\u0026thinsp;82, 74.5%).\u003c/p\u003e \u003cp\u003eAssociated anomalies were present in 68 patients (61.8%), including vertebral (30.9%), cardiac (25.5%), renal (34.5%), and limb anomalies (7.3%). VACTERL association was identified in 12 patients (10.9%), sacral anomalies in 42 (38.2%), and urinary tract pathology in 36 (32.7%). Neurosurgical intervention was documented in 24 patients (21.8%).\u003c/p\u003e \u003cp\u003eCategorical continence distributions differed significantly among the three scoring systems (p\u0026thinsp;=\u0026thinsp;0.027), with poor continence rates of 18.2% (Kelly), 10.9% (Holschneider), and 17.3% (Templeton).\u003c/p\u003e \u003cp\u003eSpearman analyses showed moderate correlations among all score pairs (ρ\u0026thinsp;=\u0026thinsp;0.52\u0026ndash;0.68; all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Weighted kappa indicated substantial agreement for Kelly\u0026ndash;Holschneider and Holschneider\u0026ndash;Templeton, and moderate agreement for Kelly\u0026ndash;Templeton.\u003c/p\u003e \u003cp\u003eIn multivariable models, neurosurgical intervention and urinary tract pathology were independent predictors of poor continence across all three score systems. High-type ARM and sacral anomaly showed score-dependent effects.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Clinical Characteristics of the Study Cohort (N\u0026thinsp;=\u0026thinsp;110)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) or Median (IQR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72 (65.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (34.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at assessment, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.8 (4.2\u0026ndash;10.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at definitive repair, months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.5 (5.0\u0026ndash;14.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eARM type: high\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48 (43.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eARM type: intermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (27.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eARM type: low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (29.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePSARP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e82 (74.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (25.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociated anomalies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68 (61.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertebral anomalies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34 (30.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac anomalies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (25.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal anomalies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (34.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLimb anomalies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (7.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVACTERL association\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (10.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSacral anomaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (38.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSacral ratio (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurosurgical intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (21.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract pathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36 (32.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eARM, anorectal malformation; IQR, interquartile range; PSARP, posterior sagittal anorectoplasty; SD, standard deviation; VACTERL, vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb anomalies.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCategorical Distribution of Continence Scores (N\u0026thinsp;=\u0026thinsp;110)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContinence category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKelly n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHolschneider n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTempleton n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep valuea\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51 (46.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58 (52.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39 (35.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36 (32.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19 (17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ea Chi-square test for overall comparison across three scoring systems (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 significant).\u003c/p\u003e \u003cp\u003eKelly: good 5\u0026ndash;6, fair 3\u0026ndash;4, poor 0\u0026ndash;2. Holschneider: good 10\u0026ndash;14, fair 5\u0026ndash;9, poor 0\u0026ndash;5. Templeton: good 4\u0026ndash;4.5, fair 2\u0026ndash;3.5, poor 0\u0026ndash;1.5.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation and Categorical Agreement Between Continence Score Pairs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore pair\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpearman ρ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWeighted κ (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAgreement level\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKelly\u0026ndash;Holschneider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.652 (0.521\u0026ndash;0.783)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood (substantial)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHolschneider\u0026ndash;Templeton\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.684 (0.547\u0026ndash;0.821)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood (substantial)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKelly\u0026ndash;Templeton\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.595 (0.458\u0026ndash;0.732)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInterpretation of κ: \u0026lt;0.20 poor; 0.21\u0026ndash;0.40 fair; 0.41\u0026ndash;0.60 moderate; 0.61\u0026ndash;0.80 good; 0.81\u0026ndash;1.00 excellent.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate Logistic Regression of Predictors of Poor Continence\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKelly aOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHolschneider aOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTempleton aOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurosurgical intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.8 (2.1\u0026ndash;10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.2 (1.8\u0026ndash;15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.5 (1.9\u0026ndash;10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract pathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.6 (1.6\u0026ndash;8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.1 (1.1\u0026ndash;8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.8 (1.6\u0026ndash;9.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh-type ARM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.9 (1.2\u0026ndash;7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.1 (0.7\u0026ndash;6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.6 (1.1\u0026ndash;6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSacral anomaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.4 (1.0\u0026ndash;5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.9 (0.7\u0026ndash;5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.2 (0.9\u0026ndash;5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVACTERL association\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.8 (0.6\u0026ndash;5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.5 (0.4\u0026ndash;5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.548\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.7 (0.5\u0026ndash;5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.362\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at repair (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.02 (0.98\u0026ndash;1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.01 (0.96\u0026ndash;1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.658\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.03 (0.99\u0026ndash;1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.198\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eModels adjusted for all listed variables plus sex. Bold p values indicate significance (\u0026lt;\u0026thinsp;0.05) at journal typesetting stage.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is one of the most comprehensive single-center studies evaluating the relationship among three widely used continence scoring systems (Kelly, Holschneider, and Templeton) in patients with ARM through correlation and categorical agreement levels, and analyzing risk factors associated with poor continence. Our main finding is that despite moderate correlation (ρ\u0026thinsp;=\u0026thinsp;0.52\u0026ndash;0.68) among these three scores, the categorical agreement between score pairs varies. While the Kelly and Holschneider (κ\u0026thinsp;=\u0026thinsp;0.652) and Holschneider and Templeton (κ\u0026thinsp;=\u0026thinsp;0.684) scores demonstrated good agreement, only moderate agreement was observed between the Kelly and Templeton (κ\u0026thinsp;=\u0026thinsp;0.595) scores. These findings support our hypothesis and indicate that the scores reflect different dimensions of continence.\u003c/p\u003e \u003cp\u003eThe distribution of anatomical types among the 110 ARM patients in our series is generally consistent with large cohorts reported in the literature [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. As expected, patients with high-type ARM, cloacal anomalies, and associated vertebral or sacral anomalies demonstrated significantly worse fecal continence outcomes. These findings reaffirm the determinant role of malformation type, sacral\u0026ndash;spinal integrity, and associated major anomalies on long-term functional outcomes.\u003c/p\u003e \u003cp\u003eAgreement Between Scoring Systems\u003c/p\u003e \u003cp\u003eOne of the most striking findings of this study is the variation in the levels of agreement observed among the three scoring systems. Our Kappa analysis revealed different levels of agreement between score pairs. The Kelly and Holschneider (κ\u0026thinsp;=\u0026thinsp;0.652; 95% CI: 0.521\u0026ndash;0.783) and Holschneider and Templeton (κ\u0026thinsp;=\u0026thinsp;0.684; 95% CI: 0.547\u0026ndash;0.821) scores demonstrated good agreement, whereas only moderate agreement was observed between the Kelly and Templeton scores (κ\u0026thinsp;=\u0026thinsp;0.595; 95% CI: 0.458\u0026ndash;0.732).\u003c/p\u003e \u003cp\u003eThese findings suggest that the Kelly and Templeton scores in particular focus on different dimensions of continence. The Kelly score primarily evaluates physiological parameters such as sphincter function and soiling [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], whereas the Templeton score emphasizes social dimensions including toilet training, social acceptability, and use of protective garments [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The finding that the Holschneider score demonstrates good agreement with both scores may indicate that this score provides a broader assessment encompassing both physiological (sphincter function, soiling) and functional (rectal sensation, gas\u0026ndash;stool discrimination) parameters [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilar findings exist in the literature. Brisighelli et al., in their series of 80 patients comparing the Holschneider, Rintala, and Krickenbeck scores, reported differences that varied according to ARM type [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Shaari et al. found poor to moderate agreement (κ\u0026thinsp;=\u0026thinsp;0.256\u0026ndash;0.343) between the Kelly, Holschneider, and Krickenbeck scores and emphasized that no single score was sufficient on its own [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The higher agreement values observed in our study (κ\u0026thinsp;=\u0026thinsp;0.595\u0026ndash;0.684) may be attributable to differences in patient populations or inter-rater agreement. Mohamed et al., in their recent comprehensive review, highlighted validation deficiencies of older scoring systems and emphasized the importance of multidisciplinary assessments integrating quality-of-life measures [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite good agreement in Kappa analysis, notable discordance was observed in the categorical classification (good/fair/poor) of the scores (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The rate of poor continence was 18.2% for Kelly, 17.3% for Templeton, and 10.9% for Holschneider. This discrepancy was even more pronounced in the fair continence category: while Kelly classified 22.8% as fair, Templeton identified only 9.9% in this category. This may result from the use of different threshold values by the scores, as well as each score emphasizing a different aspect of continence. The practical implication is clear: a patient classified as having \"good\" continence by one system may be categorized as \"fair\" or \"poor\" by another. This discordance creates uncertainty in clinical decision-making and complicates cross-study comparisons.\u003c/p\u003e \u003cp\u003eThe Need for Objective Assessment\u003c/p\u003e \u003cp\u003eA useful clinical analogy can be drawn from the diagnosis of acute appendicitis. Although the Alvarado score is valuable, it has proven insufficient when used alone and is now routinely supplemented with objective imaging modalities [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Similarly, exclusive reliance on subjective clinical scores in ARM follow-up may not fully reflect the true physiological capacity. A common limitation of all three scoring systems is their dependence on patient or parent reporting, which introduces inherent subjectivity and potential recall bias [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis limitation underscores the indispensable role of objective assessment modalities. Pelvic and spinal magnetic resonance imaging (MRI) provides critical structural information about sphincter complex anatomy, levator ani integrity, and neural abnormalities [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In our series, MRI was performed in 36 patients, with pathological findings detected in 27 (24.5%). The strong relationship between pelvic MRI findings and the Holschneider score in our study suggests that this score may be more sensitive to complex anatomical variants and neurological deficits.\u003c/p\u003e \u003cp\u003eVoiding cystourethrography (VCUG) was performed in 52 patients (47.3%), revealing pathological findings in 24 (21.8%); this rate is consistent with the 20\u0026ndash;50% range reported in the literature [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Anorectal manometry measures resting and squeeze pressures, rectal compliance, and rectoanal reflexes [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Recent studies using high-resolution three-dimensional anorectal manometry have demonstrated its value in detailed sphincter assessment [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our series, patients with abnormal intraoperative stimulator findings demonstrated significantly lower postoperative continence scores across all three systems. As described by Pe\u0026ntilde;a and DeVries in the original posterior sagittal anorectoplasty technique, intraoperative electrical stimulation is a critical tool for the precise localization of the sphincter muscle complex and the levator ani muscle during surgery [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Our findings demonstrate that intraoperative stimulation findings provide valuable electrophysiological data not only for surgical technique but also for predicting postoperative continence outcomes and counseling families, consistent with Hasselbeck and Reingruber's sacral nerve stimulation study [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRisk Factors and Clinical Implications\u003c/p\u003e \u003cp\u003eOur analysis identified several factors universally associated with poor continence across all three scoring systems (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Patients with spinal pathology requiring neurosurgical intervention (tethered cord) had significantly lower continence scores across all instruments (Kelly: 1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 vs 4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9, p\u0026thinsp;=\u0026thinsp;0.001; Holschneider: 6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0 vs 11.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Templeton: 2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 vs 3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6, p\u0026thinsp;=\u0026thinsp;0.008). In our series, 9 patients (8.2%) required neurosurgical intervention (detethering) for tethered cord, a rate consistent with the 5.2% reported by Versteegh et al. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The prevalence of tethered cord in ARM patients is reported in the literature as ranging between 24% and 33.7% [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. This finding emphasizes the importance of systematic spinal screening and early neurosurgical consultation in ARM patients.\u003c/p\u003e \u003cp\u003eUrinary tract pathology similarly demonstrated consistent adverse effects across all instruments. The presence of urinary anomalies was associated with significantly lower scores across all three systems (Kelly: 3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1 vs 4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7, p\u0026thinsp;=\u0026thinsp;0.031; Holschneider: 9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9 vs 11.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2, p\u0026thinsp;=\u0026thinsp;0.019; Templeton: 3.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 vs 4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4, p\u0026thinsp;=\u0026thinsp;0.034). Fistula location, particularly rectovesical and high-type fistulas, and initial management requiring colostomy were universally associated with worse outcomes.\u003c/p\u003e \u003cp\u003eVertebral pathology was present in 22 patients (20.0%) in our series. This rate is consistent with the 12\u0026ndash;23% range reported in the literature [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. However, vertebral anomalies showed a significant association with lower Holschneider scores (p\u0026thinsp;=\u0026thinsp;0.022), highlighting the sensitivity of this score to anatomical factors affecting pelvic floor innervation. This finding suggests that the Holschneider score may be more sensitive to neurological deficits than the other scores.\u003c/p\u003e \u003cp\u003eThe documented impact of urospinal comorbidities on ARM continence outcomes is consistent with comprehensive prior evidence [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The rate of fecal soiling rises to 91% in the presence of tethered cord, compared with 63% in patients without tethered cord. Tethered cord and lumbosacral anomalies compromise pelvic floor innervation, producing dysfunction that may be resistant to surgical technique optimization alone [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Our findings strongly support the systematic early investigation of these comorbidities in every ARM patient.\u003c/p\u003e \u003cp\u003eIn contrast, perioperative factors including bowel management program implementation, anal dilation duration, and postoperative complication grade did not show consistent association with long-term continence scores. This pattern suggests that the ultimate continence prognosis is fundamentally determined by the preoperative anatomical and neurological substrate rather than perioperative management variations. However, these interventions remain critical for optimizing patient outcomes within their existing capacity. The lower rate of postoperative constipation in our series (14.5% chronic) compared with the 30\u0026ndash;80% reported in the literature [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] demonstrates the importance of close outpatient follow-up and timely implementation of bowel management programs.\u003c/p\u003e \u003cp\u003eProposed Integrated Assessment Algorithm\u003c/p\u003e \u003cp\u003eBased on the findings of this study, we propose an integrated assessment algorithm for the evaluation of fecal continence in patients with ARM (Fig.\u0026nbsp;2). This algorithm would incorporate the following elements:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eClinical scoring using at least two validated instruments (e.g., Kelly and Holschneider scores) to capture both subjective and semi-objective dimensions of continence.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eObjective functional studies, including anorectal manometry to assess sphincteric pressure profiles and rectal sensation, and endoanal ultrasonography to evaluate the structural integrity of the sphincter complex.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStandardized assessment of associated risk factors, with particular attention to a history of neurosurgical intervention and the presence of urinary tract pathology, given their consistent association with poor outcomes.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eQuality-of-life assessment using validated instruments (e.g., the Pediatric Quality of Life Inventory or the Fecal Incontinence Quality of Life Scale) to capture the patient's and family's subjective experience of continence.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLongitudinal follow-up with repeated assessments at standardized intervals to capture temporal changes in continence status, particularly during critical developmental periods.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThis integrated approach would provide a more comprehensive, reproducible, and clinically meaningful evaluation of continence outcomes, facilitating evidence-based decision-making and more robust cross-study comparisons.\u003c/p\u003e \u003cp\u003eStrengths, Limitations, and Future Directions\u003c/p\u003e \u003cp\u003eThis study has several important strengths. Our cohort of 110 patients represents one of the largest single-center series simultaneously comparing multiple continence scoring systems. The use of multivariate analysis independently for each scoring system provides robust evidence of differential risk factor sensitivity. High inter-rater agreement (κ\u0026thinsp;=\u0026thinsp;0.85) supports data reliability. The participation of four different surgeons enhances generalizability beyond single-surgeon technical variations. Furthermore, it is one of the first studies to apply the Clavien-Dindo classification for systematic grading of postoperative complications in ARM patients.\u003c/p\u003e \u003cp\u003eHowever, several limitations must be acknowledged. The retrospective design introduces potential selection and information biases. As a single-center study, the findings may not be fully generalizable to other populations with different referral patterns or surgical practices. Thirteen patients (11.8%) could not be reached for follow-up scoring; however, their demographic and surgical characteristics did not differ significantly from the assessed cohort. Additionally, continence scores are inherently subjective, and parent-reported data for young children may contain reporting bias [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Notable differences between parent and patient reports have been observed, particularly for psychosocial variables [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFuture research should prioritize prospective validation of integrated assessment algorithms in multicenter settings. Studies comparing the predictive validity of clinical scores versus objective tests for patient-related outcomes (quality of life, social participation) are needed. Cost-effectiveness analyses of tiered assessment protocols will inform resource allocation. Long-term studies following patients into adulthood will clarify whether childhood continence patterns predict adult functional outcomes [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. The development of structured transition programs and multidisciplinary adult care protocols is critically important for optimal outcomes in this patient group [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe Kelly, Holschneider, and Templeton fecal continence scores demonstrate moderate correlation when applied simultaneously to patients with anorectal malformations. While good agreement exists between Kelly\u0026ndash;Holschneider and Holschneider\u0026ndash;Templeton score pairs, agreement between Kelly and Templeton is only moderate. The notable discordance in categorical classification\u0026mdash;with the rate of poor continence varying from 10.9% to 18.2% depending on the scoring system used\u0026mdash;underscores the risk of relying on a single instrument for outcome assessment. Neurosurgical intervention and urinary tract pathology are robust, score-independent predictors of poor fecal continence. These factors should be given particular attention during preoperative counseling and postoperative surveillance. We recommend the adoption of a multimodal assessment algorithm that integrates multiple clinical continence scores with objective functional studies (e.g., anorectal manometry, endoanal ultrasonography) to provide a comprehensive and reliable evaluation of continence outcomes in patients with ARM. Future multicenter, prospective studies with larger sample sizes and longitudinal follow-up are warranted to validate these findings and to develop a standardized, universally accepted continence assessment framework.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eFunding: No funds, grants, or other support was received.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003eEthics approval: This study protocol was approved by the \u0026Ccedil;ukurova University Faculty of Medicine Ethics Committee on April 10, 2020 (Meeting No: 98, Decision No: N-5).\u003c/p\u003e\n\u003cp\u003eConsent to participate: Informed consent was obtained from parents/legal guardians.\u003c/p\u003e\n\u003cp\u003eData availability: The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eAuthor Contributions: Galib Bayramov: Conceptualization, Methodology, Data curation, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing, Supervision. \u0026Ouml;nder \u0026Ouml;zden: Formal analysis, Investigation, Resources, Writing \u0026ndash; review \u0026amp; editing. H\u0026uuml;lya Binokay: Methodology, Resources, Formal analysis, Writing \u0026ndash; review \u0026amp; editing. Recep Tuncer: Supervision, Formal analysis, Writing \u0026ndash; review \u0026amp; editing. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003eAcknowledgments: None\u003c/p\u003e\n\u003cp\u003eAuthor Contact Information (for submission system)\u003c/p\u003e\n\u003cp\u003eGalib Bayramov: [email protected]\u003c/p\u003e\n\u003cp\u003e\u0026Ouml;nder \u0026Ouml;zden: [email protected]\u003c/p\u003e\n\u003cp\u003eH\u0026uuml;lya Binokay: [email protected]\u003c/p\u003e\n\u003cp\u003eRecep Tuncer: [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLevitt MA, Pe\u0026ntilde;a A. Anorectal malformations. Orphanet J Rare Dis. 2007;2:33. https://doi.org/10.1186/1750-1172-2-33\u003c/li\u003e\n\u003cli\u003eStoll C, Alembik Y, Dott B, Roth MP. Risk factors in congenital anal atresias. Ann Genet. 1997;40(4):197-204.\u003c/li\u003e\n\u003cli\u003eCuschieri A, EUROCAT Working Group. Anorectal anomalies associated with or as part of other anomalies. Am J Med Genet. 2002;110(2):122-130. https://doi.org/10.1002/ajmg.10371\u003c/li\u003e\n\u003cli\u003ede Vries PA, Pe\u0026ntilde;a A. Posterior sagittal anorectoplasty. J Pediatr Surg. 1982;17(5):638-643. https://doi.org/10.1016/s0022-3468(82)80123-7\u003c/li\u003e\n\u003cli\u003ePe\u0026ntilde;a A, DeVries PA. Posterior sagittal anorectoplasty: important technical considerations and new applications. J Pediatr Surg. 1982;17(6):796-811. https://doi.org/10.1016/s0022-3468(82)80448-x\u003c/li\u003e\n\u003cli\u003eKyrklund K, Pakarinen MP, Koivusalo A, Rintala RJ. Long-term bowel functional outcomes in patients with anorectal malformations treated during the PSARP era. Semin Pediatr Surg. 2017;26(5):336-342. https://doi.org/10.1053/j.sempedsurg.2017.09.007\u003c/li\u003e\n\u003cli\u003eKyrklund K, Koivusalo A, Rintala RJ, Pakarinen MP. Evaluation of bowel function and fecal continence in 594 Finnish patients with anorectal malformations diagnosed during 1983-2014. J Pediatr Surg. 2017;52(8):1266-1272. https://doi.org/10.1016/j.jpedsurg.2017.01.001\u003c/li\u003e\n\u003cli\u003eWitvliet MJ, Sleeboom C, de Jong TP, et al. Quality of life and self-esteem of children treated for anorectal malformation. J Pediatr Surg. 2014;49(1):49-53. https://doi.org/10.1016/j.jpedsurg.2013.09.033\u003c/li\u003e\n\u003cli\u003eDiseth TH, Emblem R, Solbraa K, et al. Mental health and psychosocial functioning in adolescents with anorectal anomalies or Hirschsprung\u0026apos;s disease. Arch Dis Child. 1998;78(4):362-368. https://doi.org/10.1136/adc.78.4.362\u003c/li\u003e\n\u003cli\u003eKelly JH. The clinical and radiological assessment of anal continence in childhood. Aust N Z J Surg. 1972;42(1):62-63. https://doi.org/10.1111/j.1445-2197.1972.tb06734.x\u003c/li\u003e\n\u003cli\u003eHolschneider AM, Hutson JM, eds. Anorectal Malformations in Children: Embryology, Diagnosis, Surgical Treatment, Follow-up. Springer; 2006. https://doi.org/10.1007/978-3-540-31751-7\u003c/li\u003e\n\u003cli\u003eHolschneider A, Hutson J, Pe\u0026ntilde;a A, et al. Preliminary report on the International Conference for the Development of Standards for the Treatment of Anorectal Malformations. J Pediatr Surg. 2005;40(10):1521-1526. https://doi.org/10.1016/j.jpedsurg.2005.07.036\u003c/li\u003e\n\u003cli\u003eTempleton JM Jr, Ditesheim JA. High imperforate anus--quantitative results of long-term fecal continence. J Pediatr Surg. 1985;20(6):645-652. https://doi.org/10.1016/s0022-3468(85)80017-3\u003c/li\u003e\n\u003cli\u003eBrisighelli G, Macchini F, Consonni D, et al. Continence after posterior sagittal anorectoplasty for anorectal malformations: comparison of different scores. J Pediatr Surg. 2018;53(9):1727-1733. https://doi.org/10.1016/j.jpedsurg.2018.04.010\u003c/li\u003e\n\u003cli\u003eShaari MK, Tan YW, Abdullah MY, et al. Comparing consistency and usability of common bowel function scoring systems in anorectal malformation patients. J Pediatr Surg. 2024;59(4):571-576. https://doi.org/10.1016/j.jpedsurg.2023.07.033\u003c/li\u003e\n\u003cli\u003eMohamed MS, Assiri AN, Abosheisha M, et al. Clinical scoring systems for the assessment of continence following anorectal malformation repair: a comprehensive review. Cureus. 2025;17(8):e89254. https://doi.org/10.7759/cureus.89254\u003c/li\u003e\n\u003cli\u003eEndo M, Hayashi A, Ishihara M, et al. Analysis of 1,992 patients with anorectal malformations over the past two decades in Japan. J Pediatr Surg. 1999;34(3):435-441.\u003c/li\u003e\n\u003cli\u003eCho S, Moore SP, Fangman T. One hundred three consecutive patients with anorectal malformations and their associated anomalies. Arch Pediatr Adolesc Med. 2001;155(5):587-591. https://doi.org/10.1001/archpedi.155.5.587\u003c/li\u003e\n\u003cli\u003eT\u0026eacute;oule P, de Laffolie J, Rolle U, Reissfelder C. Acute Appendicitis in Childhood and Adulthood: An Everyday Clinical Challenge. Dtsch Arztebl Int. 2020;117(44):764-774. https://doi.org/10.3238/arztebl.2020.0764\u003c/li\u003e\n\u003cli\u003eBhangu A, S\u0026oslash;reide K, Di Saverio S, et al. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015;386(10000):1278-1287.\u003c/li\u003e\n\u003cli\u003eMert M, Sayan A, K\u0026ouml;yl\u0026uuml;oğlu G. Comparing the fecal continence scores of patients with anorectal malformation with anorectal manometric findings. Pediatr Surg Int. 2021;37(8):1013-1019. https://doi.org/10.1007/s00383-021-04884-4\u003c/li\u003e\n\u003cli\u003eCaruso AM, Bommarito D, Girgenti V, et al. Evaluation of long-term results in patients with anorectal malformations. Pediatr Surg Int. 2019;35(2):227-233. https://doi.org/10.1007/s00383-018-4399-2\u003c/li\u003e\n\u003cli\u003eSu SK, Chen HC, Chou CM, et al. Routine whole spine magnetic resonance imaging for patients with anorectal malformations. Sci Rep. 2024;14:22217. https://doi.org/10.1038/s41598-024-73017-3\u003c/li\u003e\n\u003cli\u003eEsposito G, Totonelli G, Morini F, et al. Predictive value of spinal bone anomalies for spinal cord abnormalities in patients with anorectal malformations. J Pediatr Surg. 2021;56(10):1803-1810. https://doi.org/10.1016/j.jpedsurg.2021.05.011\u003c/li\u003e\n\u003cli\u003eKirby G, Zarifa I, Elkassaby A, et al. Systematic review of ultrasound and MRI prediction of spinal cord anomalies in children with anorectal malformations. World J Pediatr Surg. 2025;8(1):e000978. https://doi.org/10.1136/wjps-2024-000978\u003c/li\u003e\n\u003cli\u003eFuchs ME, Halleran DR, Bourgeois T, et al. Correlation of anorectal malformation complexity and associated urologic abnormalities. J Pediatr Surg. 2021;56(11):1988-1992. https://doi.org/10.1016/j.jpedsurg.2021.02.051\u003c/li\u003e\n\u003cli\u003eHarwood R, Reid T, Salim A, et al. Routine evaluation of vesico-ureteric reflux in children with anorectal malformation does not reduce the rate of urinary tract infection. J Pediatr Surg. 2021;56(10):1811-1815. https://doi.org/10.1016/j.jpedsurg.2021.02.062\u003c/li\u003e\n\u003cli\u003eWondemagegnehu BD, Asfaw SW. Urogenital anomalies in children with anorectal malformations: a single institution observational study. Front Surg. 2025;12:1497644. https://doi.org/10.3389/fsurg.2025.1497644\u003c/li\u003e\n\u003cli\u003eAthanasakos E, Cleeve S, Thapar N, et al. Anorectal manometry in children with defecation disorders BSPGHAN Motility Working Group consensus statement. Neurogastroenterol Motil. 2020;32(6):e13797. https://doi.org/10.1111/nmo.13797\u003c/li\u003e\n\u003cli\u003eCaruso AM, Bommarito D, Girgenti V, et al. Evaluation of Anal Sphincter with High Resolution Anorectal Manometry and 3D Reconstruction in Patients with Anorectal Malformation. Children (Basel). 2023;10(6):1037. https://doi.org/10.3390/children10061037\u003c/li\u003e\n\u003cli\u003eHasselbeck C, Reingruber B. Sacral nerve stimulation is a valuable diagnostic tool in the management of anorectal and pelvic malformations. J Pediatr Surg. 2012;47(7):1466-1471. https://doi.org/10.1016/j.jpedsurg.2012.03.091\u003c/li\u003e\n\u003cli\u003eDestro F, Canazza L, Meroni M, et al. Tethered Cord and Anorectal Malformations: A Case Series. Eur J Pediatr Surg. 2018;28(6):484-490. https://doi.org/10.1055/s-0037-1606844\u003c/li\u003e\n\u003cli\u003eKarrer FM, Flannery AM, Nelson MD, McLone DG, Raffensperger JG. Anorectal malformations: Evaluation of associated spinal dysraphic syndromes. J Pediatr Surg. 1988;23(1):45-48. https://doi.org/10.1016/S0022-3468(88)80538-4\u003c/li\u003e\n\u003cli\u003eSuppiej A, Dal Zotto L, Cappellari A, et al. Tethered cord in patients with anorectal malformation: preliminary results. Pediatr Surg Int. 2009;25(10):851-855. https://doi.org/10.1007/s00383-009-2435-6\u003c/li\u003e\n\u003cli\u003eWondemagegnehu BD, Asfaw SW, Mamo TN, et al. Incidence of associated anomalies in children with anorectal malformations: A 1-year prospective observational study in a low-income setting. Medicine (Baltimore). 2024;103(38):e39811. https://doi.org/10.1097/MD.0000000000039811\u003c/li\u003e\n\u003cli\u003eOh C, Youn JK, Han JW, et al. Analysis of Associated Anomalies in Anorectal Malformations: Major and Minor Anomalies. J Korean Med Sci. 2020;35(14):e98. https://doi.org/10.3346/jkms.2020.35.e98\u003c/li\u003e\n\u003cli\u003eHeij HA, Nievelstein RA, de Zwart I, et al. Abnormal anatomy of the lumbosacral region imaged by magnetic resonance in children with anorectal malformations. Arch Dis Child. 1996;74(5):441-444. https://doi.org/10.1136/adc.74.5.441\u003c/li\u003e\n\u003cli\u003eTuuha SE, Aziz D, Drake J, Wales P, Kim PC. Is surgery necessary for asymptomatic tethered cord in anorectal malformation patients? J Pediatr Surg. 2004;39(5):773-777. https://doi.org/10.1016/j.jpedsurg.2004.01.035\u003c/li\u003e\n\u003cli\u003eLevitt MA, Patel M, Rodriguez G, Gaylin DS, Pena A. The tethered spinal cord in patients with anorectal malformations. J Pediatr Surg. 1997;32(3):462-468. https://doi.org/10.1016/s0022-3468(97)90607-2\u003c/li\u003e\n\u003cli\u003eBoemers TM, de Jong TP, van Gool JD, Bax KM. Urologic problems in anorectal malformations. Part 2: functional urologic sequelae. J Pediatr Surg. 1996;31(5):634-637. https://doi.org/10.1016/s0022-3468(96)90663-6\u003c/li\u003e\n\u003cli\u003eGarvey EM, Fuller M, Frischer J, et al. Multi-Institutional Review From the Pediatric Colorectal and Pelvic Learning Consortium of Minor Spinal Cord Dysraphism in the Setting of Anorectal Malformations: Diagnosis, Treatment, and Outcomes. J Pediatr Surg. 2023;58(8):1582-1587. https://doi.org/10.1016/j.jpedsurg.2023.04.009\u003c/li\u003e\n\u003cli\u003eDi Cesare A, Leva E, Macchini F, et al. Anorectal malformations and neurospinal dysraphism: is this association a major risk for continence? Pediatr Surg Int. 2010;26(11):1077-1081. https://doi.org/10.1007/s00383-010-2686-2\u003c/li\u003e\n\u003cli\u003eBokova E, Svetanoff WJ, Lopez JJ, Levitt MA, Rentea RM. State of the Art Bowel Management for Pediatric Colorectal Problems: Anorectal Malformations. Children (Basel). 2023;10(5):846. https://doi.org/10.3390/children10050846\u003c/li\u003e\n\u003cli\u003eLevitt MA, Kant A, Pe\u0026ntilde;a A. The morbidity of constipation in patients with anorectal malformations. J Pediatr Surg. 2010;45(6):1228-1233. https://doi.org/10.1016/j.jpedsurg.2010.02.096\u003c/li\u003e\n\u003cli\u003eWood RJ, Srinivas S, Trajanovska M, et al. Patient-reported outcomes of Children with an Anorectal Malformation. Ann Surg. 2024. https://doi.org/10.1097/SLA.0000000000006606\u003c/li\u003e\n\u003cli\u003eHassan L, Rosenberg CBM, Cortenraad SAM, et al. Anorectal malformation and outcome review (ARMOUR) project: a systematic review for the outcomes reported in patients with an anorectal malformation. BMJ Paediatrics Open. 2025;9:e003192. https://doi.org/10.1136/bmjpo-2024-003192\u003c/li\u003e\n\u003cli\u003eWitvliet MJ, Petersen J, Sleeboom C, et al. Adult outcomes in patients with anorectal malformations: a systematic review. Dis Colon Rectum. 2009;52(11):1892-1903. https://doi.org/10.1007/DCR.0b013e3181b44c4e\u003c/li\u003e\n\u003cli\u003eKyrklund K, Pakarinen MP, Rintala RJ. Long-term outcomes in anorectal malformations: a systematic review. Semin Pediatr Surg. 2016;25(5):295-302. https://doi.org/10.1053/j.sempedsurg.2016.09.001\u003c/li\u003e\n\u003cli\u003eVersteegh HP, Sutcliffe JR, Sloots CEJ, et al. Renal and bladder outcomes in young adults with anorectal malformations. J Pediatr Surg. 2022;57(8):1567-1572. https://doi.org/10.1016/j.jpurol.2022.03.015\u003c/li\u003e\n\u003cli\u003eRentea RM, Halleran DR, Ahmad H, et al. Transitional care for adolescents and adults with anorectal malformations. J Pediatr Surg. 2023;58(12):2345-2352. https://doi.org/10.1016/j.jpedsurg.2023.09.045\u003c/li\u003e\n\u003cli\u003eKyrklund K, Koivusalo A, Rintala RJ, Pakarinen MP. Transitional care in anorectal malformations: an international survey. J Pediatr Surg. 2020;55(11):2345-2351. https://doi.org/10.1016/j.jpedsurg.2020.08.012\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"anorectal malformation, fecal continence, Kelly score, Holschneider score, Templeton score, agreement analysis","lastPublishedDoi":"10.21203/rs.3.rs-9430654/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9430654/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo evaluate inter-score correlation and categorical agreement among the Kelly, Holschneider, and Templeton fecal continence scores in patients with anorectal malformations (ARM), and to identify predictors of poor continence.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this retrospective single-center cohort, 110 surgically treated ARM patients (2007\u0026ndash;2017) were assessed at latest follow-up using all three scores. Correlation was tested with Spearman analysis, categorical agreement with weighted kappa, and independent risk factors with multivariable logistic regression for each scoring system.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCorrelations were moderate and significant across all pairs (ρ\u0026thinsp;=\u0026thinsp;0.52\u0026ndash;0.68; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Agreement was substantial between Kelly\u0026ndash;Holschneider (κ\u0026thinsp;=\u0026thinsp;0.652) and Holschneider\u0026ndash;Templeton (κ\u0026thinsp;=\u0026thinsp;0.684), but moderate between Kelly\u0026ndash;Templeton (κ\u0026thinsp;=\u0026thinsp;0.595). Poor continence rates differed by instrument (Kelly 18.2%, Holschneider 10.9%, Templeton 17.3%). Neurosurgical intervention and urinary tract pathology independently predicted poor continence in all models.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAlthough the three scores are correlated, clinically meaningful categorical discordance exists. Single-score assessment may therefore be misleading. Combined use of multiple validated continence scores with objective functional assessment is recommended for comprehensive ARM follow-up.\u003c/p\u003e","manuscriptTitle":"Comparative Analysis of Three Fecal Continence Scores in Patients with Anorectal Malformations: Inter-Score Agreement and Prognostic Factors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-24 04:53:58","doi":"10.21203/rs.3.rs-9430654/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-06T15:38:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T14:57:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T12:37:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"224001069717096969509810064950517103269","date":"2026-04-28T09:14:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102973261827082551051737739937443449901","date":"2026-04-23T07:59:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-23T07:22:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-21T09:49:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-21T01:36:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Surgery International","date":"2026-04-15T19:27:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"93915a54-2b22-44ec-800d-1207f8fd5f74","owner":[],"postedDate":"April 24th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-06T15:38:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T14:57:50+00:00","index":12,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T12:37:41+00:00","index":11,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-17T10:08:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-24 04:53:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9430654","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9430654","identity":"rs-9430654","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}