Title: Abnormal anorectal manometric and sensory functions in patients with functional
anorectal pain
Version: 4 Date: 01 May 2025
Reviewer's report:
Overall the paper is well-written. There should be final proof-reading for several small
grammatical errors. In terms of the subject and findings it is a paper with few similar
previous reports and thus interesting. It lacks however clarification regarding the FARP and its
subdivisions. Your paper put them all in one category and later in the discussion spoke about
findings in FGID  IBS type pain and levator ani syndrome type pain. I have given ideas to expand
or clarify some text that is unclear or ambiguous. Please try to explain better in your discussion.
See below:
Your discussion starts with this:
"Our findings have contributed to a better understanding of the pathophysiology of this
condition. We have identified characteristics of abnormal rectal sensitivity and anorectal
pressure as well as anorectal discoordination during defecation in FARP, providing a basis for
diagnosis and staging of this condition. We also explored the psychological characteristics of
patients with FARP and found that comorbid mood disorders are common in patients with FARP.
Our findings pave the way for a new approach for future treatment."
1. How did you apply your findings to staging and diagnosis exactly?
2. If you tested for anxiety and depression, you should have asked about past trauma such as
sexual, physical, emotional abuse and traumatic events because these can also lead to anxiety,
depression and functional bowel disorders such as pain and ODS.
3. You mention anorectal discoordination, perhaps you speak of paradoxal movement,
dyssynergic defecation or anismus. This disorder is frequently linked with childhood or past
trauma and should be part of your history. This is also frequently linked to anorectal pain with
puborectalis contraction or levator ani syndrome.
4. How are you able to propose a new approach to treatments, psychiatric meds such as
antidepressants are already used?
5. Anorectal pain could be caused not only by anal sphincter contraction as you mentioned but
also puborectalis hypercontraction. This can occur in post trauma patients or those who fear
incontinence
You also wrote:
"In this study, resting anal pressure and maximum anal squeeze pressure were significantly lower
in the patients with FARP than in the controls, and the pelvic floor muscles were predominantly
flaccid, which is consistent with previous findings."
1. How did you measure the flaccidity of the pelvic floor muscles to know they were flaccid?
"There was no statistically significant difference in the overall frequency of combined defecation
coordination disorders between the FARP group and the control group (42.86% vs 41.82%;
Table 1). The same results were found in female FARP patients compared with female healthy
controls (Table 2). However, the proportion of men with defecation coordination disorder was
significantly higher in the FARP group than in the control group (76,92% vs 50%; P<0.05; Table
3 and Fig.4). Furthermore, in the FARP group, women were significantly less likely than men
to have defecation coordination disorder (29,79% vs 76.92%; P<0.001; Table 4 and Fig. 3)."
1. How can you explain this sex difference? Is it only a chance finding because you mixed the
IBS type or pain with the Levator ani type pain and had more males with LA type ? When
you chose the FARP patients was there a question asking if they had difficulty passing stools,
constipation or difficulty passing urine?
Title: Abnormal anorectal manometric and sensory functions in patients with functional
anorectal pain
Version: 4 Date: 01 May 2025
Reviewer's report:
Overall the paper is well-written. There should be final proof-reading for several small
grammatical errors. In terms of the subject and findings it is a paper with few similar
previous reports and thus interesting. It lacks however clarification regarding the FARP and its
subdivisions. Your paper put them all in one category and later in the discussion spoke about
findings in FGID  IBS type pain and levator ani syndrome type pain. I have given ideas to expand
or clarify some text that is unclear or ambiguous. Please try to explain better in your discussion.
See below:
Your discussion starts with this:
"Our findings have contributed to a better understanding of the pathophysiology of this
condition. We have identified characteristics of abnormal rectal sensitivity and anorectal
pressure as well as anorectal discoordination during defecation in FARP, providing a basis for
diagnosis and staging of this condition. We also explored the psychological characteristics of
patients with FARP and found that comorbid mood disorders are common in patients with FARP.
Our findings pave the way for a new approach for future treatment."
1. How did you apply your findings to staging and diagnosis exactly?
2. If you tested for anxiety and depression, you should have asked about past trauma such as
sexual, physical, emotional abuse and traumatic events because these can also lead to anxiety,
depression and functional bowel disorders such as pain and ODS.
3. You mention anorectal discoordination, perhaps you speak of paradoxal movement,
dyssynergic defecation or anismus. This disorder is frequently linked with childhood or past
trauma and should be part of your history. This is also frequently linked to anorectal pain with
puborectalis contraction or levator ani syndrome.
4. How are you able to propose a new approach to treatments, psychiatric meds such as
antidepressants are already used?
5. Anorectal pain could be caused not only by anal sphincter contraction as you mentioned but
also puborectalis hypercontraction. This can occur in post trauma patients or those who fear
incontinence
You also wrote:
"In this study, resting anal pressure and maximum anal squeeze pressure were significantly lower
in the patients with FARP than in the controls, and the pelvic floor muscles were predominantly
flaccid, which is consistent with previous findings."
1. How did you measure the flaccidity of the pelvic floor muscles to know they were flaccid?
"There was no statistically significant difference in the overall frequency of combined defecation
coordination disorders between the FARP group and the control group (42.86% vs 41.82%;
Table 1). The same results were found in female FARP patients compared with female healthy
controls (Table 2). However, the proportion of men with defecation coordination disorder was
significantly higher in the FARP group than in the control group (76,92% vs 50%; P<0.05; Table
3 and Fig.4). Furthermore, in the FARP group, women were significantly less likely than men
to have defecation coordination disorder (29,79% vs 76.92%; P<0.001; Table 4 and Fig. 3)."
1. How can you explain this sex difference? Is it only a chance finding because you mixed the
IBS type or pain with the Levator ani type pain and had more males with LA type ? When
you chose the FARP patients was there a question asking if they had difficulty passing stools,
constipation or difficulty passing urine?
Please review this paper.
user
Title: Abnormal anorectal manometric and sensory functions in patients with functional
anorectal pain
Version: 4 Date: 01 May 2025
Reviewer's report:
Overall the paper is well-written. There should be final proof-reading for several small
grammatical errors. In terms of the subject and findings it is a paper with few similar
previous reports and thus interesting. It lacks however clarification regarding the FARP and its
subdivisions. Your paper put them all in one category and later in the discussion spoke about
findings in FGID  IBS type pain and levator ani syndrome type pain. I have given ideas to expand
or clarify some text that is unclear or ambiguous. Please try to explain better in your discussion.
See below:
Your discussion starts with this:
"Our findings have contributed to a better understanding of the pathophysiology of this
condition. We have identified characteristics of abnormal rectal sensitivity and anorectal
pressure as well as anorectal discoordination during defecation in FARP, providing a basis for
diagnosis and staging of this condition. We also explored the psychological characteristics of
patients with FARP and found that comorbid mood disorders are common in patients with FARP.
Our findings pave the way for a new approach for future treatment."
1. How did you apply your findings to staging and diagnosis exactly?
2. If you tested for anxiety and depression, you should have asked about past trauma such as
sexual, physical, emotional abuse and traumatic events because these can also lead to anxiety,
depression and functional bowel disorders such as pain and ODS.
3. You mention anorectal discoordination, perhaps you speak of paradoxal movement,
dyssynergic defecation or anismus. This disorder is frequently linked with childhood or past
trauma and should be part of your history. This is also frequently linked to anorectal pain with
puborectalis contraction or levator ani syndrome.
4. How are you able to propose a new approach to treatments, psychiatric meds such as
antidepressants are already used?
5. Anorectal pain could be caused not only by anal sphincter contraction as you mentioned but
also puborectalis hypercontraction. This can occur in post trauma patients or those who fear
incontinence
You also wrote:
"In this study, resting anal pressure and maximum anal squeeze pressure were significantly lower
in the patients with FARP than in the controls, and the pelvic floor muscles were predominantly
flaccid, which is consistent with previous findings."
1. How did you measure the flaccidity of the pelvic floor muscles to know they were flaccid?
"There was no statistically significant difference in the overall frequency of combined defecation
coordination disorders between the FARP group and the control group (42.86% vs 41.82%;
Table 1). The same results were found in female FARP patients compared with female healthy
controls (Table 2). However, the proportion of men with defecation coordination disorder was
significantly higher in the FARP group than in the control group (76,92% vs 50%; P<0.05; Table
3 and Fig.4). Furthermore, in the FARP group, women were significantly less likely than men
to have defecation coordination disorder (29,79% vs 76.92%; P<0.001; Table 4 and Fig. 3)."
1. How can you explain this sex difference? Is it only a chance finding because you mixed the
IBS type or pain with the Levator ani type pain and had more males with LA type ? When
you chose the FARP patients was there a question asking if they had difficulty passing stools,
constipation or difficulty passing urine?
assistant