Title: Effect of posture on anorectal manometric measurements in female patients with fecal
incontinence and rectoanal intussusception
Version: 6 Date: 24 Oct 2022
Reviewer's report:
Dear authors,
Thank you for the revised version of your manuscript. Most of my comments have been
incorporated but there are still a few points, which I would like to mention:
1. The authors added Figure 1 which explains how they determined the lenght of the anal canal.
There are however some desturbing details in this Figure:
- in the left corner there are some letters in Japaneese (?), which are not to be understood; they
need to be either removed (if not relevant) or translated to English
- on the right site (in green) there is the following text: ''Max. Urethral Closure Pressure'' - I
assume authors have used an equipement, which is normally used for urethra but for this study
I it was not the urethral pressure measured, isn't it?
2. Authors have added some information in the introduction and methods, but no references.
For instance:
- the majority of patients looses its feces in erect position - is it so? is it only your ''local''
observation? Is it just an ''impression'' or a quantified observation (I mean a prevalence?). Has
it been observed by others (references?)?
- you mention the anal external continence reflex - is this reflex so well known that it does not
require any reference?
- you say that you used a validated method to calculate the lenght of the anal canal - who has
validated it? could you reffer to the validation paper/method?
3. I disagree with the conclusion - as the other reviewer also mentioned, the difference in
the squeeze pressure does not seem to be clinically relevant. Moreover, also other parameters
presented in Table 3 are statistically significantelly different, for instance the maximum resting
pressure, which is also often considered to be crucial in fecal continence.  The authors do not
conclude on it - why?
4. In the discussion authors mention the urge FI, passive FI but it is not said how did they define
the urge and passive FI (according to which criteria) - the FI severity index scores and CSS
scores do not approach this issue.
5. In the discussion the authors mention only the external sphincter (i.e. voluntary squeeze) - but
this is only a small ''part'' of the whole (in)continence machinery - what about the involuntary
contraction of the internal anal sphincter, which is claimed to contribute to 80% of the resting
pressure, and thus fecal continence? what about the involuntary  contraction of external anal
sphicnter (the anal external sphincter continence reflex)?  If the authors did not measure these
pressures (of the involuntary contractions) they should a least point it out as a severe limitation
- maybe this should be specifically mentioned in the ''future study'' because at this moment the
''future study''' is mentioned in a very assecurative way - as if the authors did not exactely knew
what to investigate in the future.
6. I still miss explanation about other parameters which were significantelly different (Table 3):
the defecation desire volume and the max. tolerated volume, which where higher in the erect
position - why were they signficantelly higher? do the authors think these parameters have also
something to do with FI?
Title: Effect of posture on anorectal manometric measurements in female patients with fecal
incontinence and rectoanal intussusception
Version: 6 Date: 24 Oct 2022
Reviewer's report:
Dear authors,
Thank you for the revised version of your manuscript. Most of my comments have been
incorporated but there are still a few points, which I would like to mention:
1. The authors added Figure 1 which explains how they determined the lenght of the anal canal.
There are however some desturbing details in this Figure:
- in the left corner there are some letters in Japaneese (?), which are not to be understood; they
need to be either removed (if not relevant) or translated to English
- on the right site (in green) there is the following text: ''Max. Urethral Closure Pressure'' - I
assume authors have used an equipement, which is normally used for urethra but for this study
I it was not the urethral pressure measured, isn't it?
2. Authors have added some information in the introduction and methods, but no references.
For instance:
- the majority of patients looses its feces in erect position - is it so? is it only your ''local''
observation? Is it just an ''impression'' or a quantified observation (I mean a prevalence?). Has
it been observed by others (references?)?
- you mention the anal external continence reflex - is this reflex so well known that it does not
require any reference?
- you say that you used a validated method to calculate the lenght of the anal canal - who has
validated it? could you reffer to the validation paper/method?
3. I disagree with the conclusion - as the other reviewer also mentioned, the difference in
the squeeze pressure does not seem to be clinically relevant. Moreover, also other parameters
presented in Table 3 are statistically significantelly different, for instance the maximum resting
pressure, which is also often considered to be crucial in fecal continence.  The authors do not
conclude on it - why?
4. In the discussion authors mention the urge FI, passive FI but it is not said how did they define
the urge and passive FI (according to which criteria) - the FI severity index scores and CSS
scores do not approach this issue.
5. In the discussion the authors mention only the external sphincter (i.e. voluntary squeeze) - but
this is only a small ''part'' of the whole (in)continence machinery - what about the involuntary
contraction of the internal anal sphincter, which is claimed to contribute to 80% of the resting
pressure, and thus fecal continence? what about the involuntary  contraction of external anal
sphicnter (the anal external sphincter continence reflex)?  If the authors did not measure these
pressures (of the involuntary contractions) they should a least point it out as a severe limitation
- maybe this should be specifically mentioned in the ''future study'' because at this moment the
''future study''' is mentioned in a very assecurative way - as if the authors did not exactely knew
what to investigate in the future.
6. I still miss explanation about other parameters which were significantelly different (Table 3):
the defecation desire volume and the max. tolerated volume, which where higher in the erect
position - why were they signficantelly higher? do the authors think these parameters have also
something to do with FI?
Please review this paper.
user
Title: Effect of posture on anorectal manometric measurements in female patients with fecal
incontinence and rectoanal intussusception
Version: 6 Date: 24 Oct 2022
Reviewer's report:
Dear authors,
Thank you for the revised version of your manuscript. Most of my comments have been
incorporated but there are still a few points, which I would like to mention:
1. The authors added Figure 1 which explains how they determined the lenght of the anal canal.
There are however some desturbing details in this Figure:
- in the left corner there are some letters in Japaneese (?), which are not to be understood; they
need to be either removed (if not relevant) or translated to English
- on the right site (in green) there is the following text: ''Max. Urethral Closure Pressure'' - I
assume authors have used an equipement, which is normally used for urethra but for this study
I it was not the urethral pressure measured, isn't it?
2. Authors have added some information in the introduction and methods, but no references.
For instance:
- the majority of patients looses its feces in erect position - is it so? is it only your ''local''
observation? Is it just an ''impression'' or a quantified observation (I mean a prevalence?). Has
it been observed by others (references?)?
- you mention the anal external continence reflex - is this reflex so well known that it does not
require any reference?
- you say that you used a validated method to calculate the lenght of the anal canal - who has
validated it? could you reffer to the validation paper/method?
3. I disagree with the conclusion - as the other reviewer also mentioned, the difference in
the squeeze pressure does not seem to be clinically relevant. Moreover, also other parameters
presented in Table 3 are statistically significantelly different, for instance the maximum resting
pressure, which is also often considered to be crucial in fecal continence.  The authors do not
conclude on it - why?
4. In the discussion authors mention the urge FI, passive FI but it is not said how did they define
the urge and passive FI (according to which criteria) - the FI severity index scores and CSS
scores do not approach this issue.
5. In the discussion the authors mention only the external sphincter (i.e. voluntary squeeze) - but
this is only a small ''part'' of the whole (in)continence machinery - what about the involuntary
contraction of the internal anal sphincter, which is claimed to contribute to 80% of the resting
pressure, and thus fecal continence? what about the involuntary  contraction of external anal
sphicnter (the anal external sphincter continence reflex)?  If the authors did not measure these
pressures (of the involuntary contractions) they should a least point it out as a severe limitation
- maybe this should be specifically mentioned in the ''future study'' because at this moment the
''future study''' is mentioned in a very assecurative way - as if the authors did not exactely knew
what to investigate in the future.
6. I still miss explanation about other parameters which were significantelly different (Table 3):
the defecation desire volume and the max. tolerated volume, which where higher in the erect
position - why were they signficantelly higher? do the authors think these parameters have also
something to do with FI?
assistant