Comparison of fecal continence and bowel function scoring systems following anorectal malformation repair: a systematic review.

PURPOSE: Multiple instruments are used to assess fecal continence and bowel function after anorectal malformation (ARM) repair, but their comparability is uncertain. This systematic review examined inter-system agreement and differences in the findings produced when two or more scoring systems were applied to the same ARM cohort.

METHODS

MEDLINE, Embase, and Web of Science were searched from inception through 26 April 2026. Original studies applying at least two named fecal continence or bowel function scoring systems to the same ARM cohort were eligible. Risk of bias was assessed using an adapted QUADAS-2 framework. Because comparable agreement estimates were sparse, results were synthesized narratively (PROSPERO: CRD420261377404).

RESULTS

Fifteen studies published from 2012 to 2025, with individual sample sizes of 20-267 participants, were included. Krickenbeck was used in 14 studies (93%) and Kelly in nine (60%). Only one study, based on 39 parent-reported assessments, reported numerical inter-system agreement estimates; weighted κ values for four score pairs ranged from 0.256 to 0.343. Other studies described category discordance or differences in group-level findings. In one cohort, Kelly did not identify a between-group difference detected by Krickenbeck and Rintala. In another small cohort, Kelly continence and the Krickenbeck constipation domain favored different surgical groups, although they assessed different outcome constructs. Blinding between instrument administrations was unreported in 12 studies.

CONCLUSION

The limited available evidence suggests that commonly used ARM bowel function instruments may yield non-equivalent information, but it is insufficient to establish their interchangeability or the superiority of any single system. Krickenbeck is currently the most frequently used instrument. Prospective comparative studies using standardized administration and appropriate agreement analyses are needed before a universal core instrument can be recommended.