Title: High-Resolution Anorectal Manometry for Diagnosing Obstructed Defecation Syndrome
Associated with Moderate Rectocele Compared to Healthy Individuals
Version: 3 Date: 07 Jun 2023
Reviewer:  Rodrigo Ambar Pinto
Reviewer's report:
First of all I would like to congratulate the authors for the great paper about HRAM in patients
with rectocele and functional defecation problems. I have some questions and considerations to
make it better and suitable for publication.
I have some major considerations to be accessed before accepting your manuscript for
publication.
Abstract
RAIR is not previously described fully. What does it refer to? Rectoanal Inhibitory Reflex? If
so, it has to be described.
How was the selection process made? Which types of rectocele were in the rectocele groups.
Also regarding the control group, how was it made? How did the authors include healthy
patients to perform HRAM? Also, was there any pairing method? Some of this important points
addressed in the manuscript have also to be  described in the abstract.
Introduction
Access and explain the problem - rectocele
Pass through different diagnostic methods for ODS evaluation - Defecography / 3D HRAM
Question 3D HRAM as a diagnostic method for ODS evaluation
States that only a few studies have addressed 3D HRAM as a diagnostic tool for ODS
I like your introduction and statement of the problem.
Objectives
Our study aims to explore the diagnostic value of 3D HRAM in healthy subjects and subjects
presenting ODS associated with MRSW and to screen out independent risk factors for the
prognosis of ODS due to moderate rectocele. Reading the manuscript I did not understand how
do the authors define and correlate the risk factors for prognosis of ODS and moderate rectocele
(this was not clear for me). That is why you will find questions about prognosis ahead.
Methods
Study design and patients
Patients - Moderate rectocele diagnosed with defecography
Controls - healthy females. Was any pairing of the control group with the study group.
SROBE was used
I think there is a lack of definitions in the methods for the results found further in the manuscript.
Could you please explain better prognosis relations for example?
Subject inclusion criteria - is this the control group? Seems to be but it is not completely clear.
Authors describe that no medication was 3 months prior to enrollment. Which types of
medications?
I expected more information about the control group..
Patient inclusion criteria
Patients diagnosed with  Rome IV criteria. What was the cutoff for the diagnosis?
Why did the authors include only mild rectoceles within 3 cm? Why not include larger
rectoceles?
Were patients treating constipation prior to the exam or just diagnosed with constipation? If
treated, what treatment were they on?
Patient exclusion criteria
The authors excluded patients with associated slow transit constipation. Why did you exclude
these patients from a diagnostic test? What difference from patients without this diagnosis would
you expect to exclude them?
All patients with associated DD  were excluded? Why?
Also the numbering from 1.2 to 1.4 is strange. I would suggest the same number for all the
inclusion and exclusion processes.
HRAM Studies
The diagnostic tool authors used (MonoScan 3D; Sierra Scientific instruments) is not worldwide
used and not so common around the world due to its cost. I would suggest you give more
information about this tool and technology.
The probe is positioned 10 to 15 cm from the anal verge. Why does it have to be so high? How
do the authors and the examiner are sure that the probe does not turn around and the tip is located
close to the anal verge?
In the last paragraph of this session beginning with HPZ all the formulas are calculated
automatically by the machine or it has to be done manually?
Results
It was good to know that the groups were homogeneous in age and BMI, however this
could be programmed and performed priorly, since the selection of patients were performed
prospectively. Why did you prefer to do it after? What if there was an heterogeneous
distribution?
2.2.2 - Authors find female age negatively related with maximum rest and squeezing pressure
in healthy women, but not in rectocele patients.
2.2.3 - how do authors explain linear logistic regression showing age as an independent factor
associated with worse maximum squeezing pressure in healthy and rectocele women
How did authors measure RAIR in the study? Water, air? How would you do together with the
rectal sensation test?
Why do authors use the word prognosis of many values found at the results, such as, maximum
squeezing pressure, age and RAIR? Would it be a diagnosis? Does it mean that the pressure, for
example, is lower in MRSW patients?
I think the large tables and the long texts with different variables and comparisons make the
results confusing? Could the authors rewrite and simplify the tables to make the results clearer?
For example, where is the logistic regression that shows that RAIR and age are independent risk
factors for the prognosis of MRSW? How do you get to this results? Also I have doubt about
what prognosis of MRSW means? Do the authors mean diagnosis of MRSW?
Discussion
How do you stratify the severity of the disease using HRAM?
I agree with your considerations regarding limitations of the study when you admit that
comparative studies with other image studies, such as 3D-US and RNM are necessary to have
this anatomical functional comparison.
What do you think were the main contributions of this study to the medical literature regarding
functional diseases of the colon and rectum? Would it change management of rectocele and
ODS from now on?
Title: High-Resolution Anorectal Manometry for Diagnosing Obstructed Defecation Syndrome
Associated with Moderate Rectocele Compared to Healthy Individuals
Version: 3 Date: 07 Jun 2023
Reviewer:  Rodrigo Ambar Pinto
Reviewer's report:
First of all I would like to congratulate the authors for the great paper about HRAM in patients
with rectocele and functional defecation problems. I have some questions and considerations to
make it better and suitable for publication.
I have some major considerations to be accessed before accepting your manuscript for
publication.
Abstract
RAIR is not previously described fully. What does it refer to? Rectoanal Inhibitory Reflex? If
so, it has to be described.
How was the selection process made? Which types of rectocele were in the rectocele groups.
Also regarding the control group, how was it made? How did the authors include healthy
patients to perform HRAM? Also, was there any pairing method? Some of this important points
addressed in the manuscript have also to be  described in the abstract.
Introduction
Access and explain the problem - rectocele
Pass through different diagnostic methods for ODS evaluation - Defecography / 3D HRAM
Question 3D HRAM as a diagnostic method for ODS evaluation
States that only a few studies have addressed 3D HRAM as a diagnostic tool for ODS
I like your introduction and statement of the problem.
Objectives
Our study aims to explore the diagnostic value of 3D HRAM in healthy subjects and subjects
presenting ODS associated with MRSW and to screen out independent risk factors for the
prognosis of ODS due to moderate rectocele. Reading the manuscript I did not understand how
do the authors define and correlate the risk factors for prognosis of ODS and moderate rectocele
(this was not clear for me). That is why you will find questions about prognosis ahead.
Methods
Study design and patients
Patients - Moderate rectocele diagnosed with defecography
Controls - healthy females. Was any pairing of the control group with the study group.
SROBE was used
I think there is a lack of definitions in the methods for the results found further in the manuscript.
Could you please explain better prognosis relations for example?
Subject inclusion criteria - is this the control group? Seems to be but it is not completely clear.
Authors describe that no medication was 3 months prior to enrollment. Which types of
medications?
I expected more information about the control group..
Patient inclusion criteria
Patients diagnosed with  Rome IV criteria. What was the cutoff for the diagnosis?
Why did the authors include only mild rectoceles within 3 cm? Why not include larger
rectoceles?
Were patients treating constipation prior to the exam or just diagnosed with constipation? If
treated, what treatment were they on?
Patient exclusion criteria
The authors excluded patients with associated slow transit constipation. Why did you exclude
these patients from a diagnostic test? What difference from patients without this diagnosis would
you expect to exclude them?
All patients with associated DD  were excluded? Why?
Also the numbering from 1.2 to 1.4 is strange. I would suggest the same number for all the
inclusion and exclusion processes.
HRAM Studies
The diagnostic tool authors used (MonoScan 3D; Sierra Scientific instruments) is not worldwide
used and not so common around the world due to its cost. I would suggest you give more
information about this tool and technology.
The probe is positioned 10 to 15 cm from the anal verge. Why does it have to be so high? How
do the authors and the examiner are sure that the probe does not turn around and the tip is located
close to the anal verge?
In the last paragraph of this session beginning with HPZ all the formulas are calculated
automatically by the machine or it has to be done manually?
Results
It was good to know that the groups were homogeneous in age and BMI, however this
could be programmed and performed priorly, since the selection of patients were performed
prospectively. Why did you prefer to do it after? What if there was an heterogeneous
distribution?
2.2.2 - Authors find female age negatively related with maximum rest and squeezing pressure
in healthy women, but not in rectocele patients.
2.2.3 - how do authors explain linear logistic regression showing age as an independent factor
associated with worse maximum squeezing pressure in healthy and rectocele women
How did authors measure RAIR in the study? Water, air? How would you do together with the
rectal sensation test?
Why do authors use the word prognosis of many values found at the results, such as, maximum
squeezing pressure, age and RAIR? Would it be a diagnosis? Does it mean that the pressure, for
example, is lower in MRSW patients?
I think the large tables and the long texts with different variables and comparisons make the
results confusing? Could the authors rewrite and simplify the tables to make the results clearer?
For example, where is the logistic regression that shows that RAIR and age are independent risk
factors for the prognosis of MRSW? How do you get to this results? Also I have doubt about
what prognosis of MRSW means? Do the authors mean diagnosis of MRSW?
Discussion
How do you stratify the severity of the disease using HRAM?
I agree with your considerations regarding limitations of the study when you admit that
comparative studies with other image studies, such as 3D-US and RNM are necessary to have
this anatomical functional comparison.
What do you think were the main contributions of this study to the medical literature regarding
functional diseases of the colon and rectum? Would it change management of rectocele and
ODS from now on?
Please review this paper.
user
Title: High-Resolution Anorectal Manometry for Diagnosing Obstructed Defecation Syndrome
Associated with Moderate Rectocele Compared to Healthy Individuals
Version: 3 Date: 07 Jun 2023
Reviewer:  Rodrigo Ambar Pinto
Reviewer's report:
First of all I would like to congratulate the authors for the great paper about HRAM in patients
with rectocele and functional defecation problems. I have some questions and considerations to
make it better and suitable for publication.
I have some major considerations to be accessed before accepting your manuscript for
publication.
Abstract
RAIR is not previously described fully. What does it refer to? Rectoanal Inhibitory Reflex? If
so, it has to be described.
How was the selection process made? Which types of rectocele were in the rectocele groups.
Also regarding the control group, how was it made? How did the authors include healthy
patients to perform HRAM? Also, was there any pairing method? Some of this important points
addressed in the manuscript have also to be  described in the abstract.
Introduction
Access and explain the problem - rectocele
Pass through different diagnostic methods for ODS evaluation - Defecography / 3D HRAM
Question 3D HRAM as a diagnostic method for ODS evaluation
States that only a few studies have addressed 3D HRAM as a diagnostic tool for ODS
I like your introduction and statement of the problem.
Objectives
Our study aims to explore the diagnostic value of 3D HRAM in healthy subjects and subjects
presenting ODS associated with MRSW and to screen out independent risk factors for the
prognosis of ODS due to moderate rectocele. Reading the manuscript I did not understand how
do the authors define and correlate the risk factors for prognosis of ODS and moderate rectocele
(this was not clear for me). That is why you will find questions about prognosis ahead.
Methods
Study design and patients
Patients - Moderate rectocele diagnosed with defecography
Controls - healthy females. Was any pairing of the control group with the study group.
SROBE was used
I think there is a lack of definitions in the methods for the results found further in the manuscript.
Could you please explain better prognosis relations for example?
Subject inclusion criteria - is this the control group? Seems to be but it is not completely clear.
Authors describe that no medication was 3 months prior to enrollment. Which types of
medications?
I expected more information about the control group..
Patient inclusion criteria
Patients diagnosed with  Rome IV criteria. What was the cutoff for the diagnosis?
Why did the authors include only mild rectoceles within 3 cm? Why not include larger
rectoceles?
Were patients treating constipation prior to the exam or just diagnosed with constipation? If
treated, what treatment were they on?
Patient exclusion criteria
The authors excluded patients with associated slow transit constipation. Why did you exclude
these patients from a diagnostic test? What difference from patients without this diagnosis would
you expect to exclude them?
All patients with associated DD  were excluded? Why?
Also the numbering from 1.2 to 1.4 is strange. I would suggest the same number for all the
inclusion and exclusion processes.
HRAM Studies
The diagnostic tool authors used (MonoScan 3D; Sierra Scientific instruments) is not worldwide
used and not so common around the world due to its cost. I would suggest you give more
information about this tool and technology.
The probe is positioned 10 to 15 cm from the anal verge. Why does it have to be so high? How
do the authors and the examiner are sure that the probe does not turn around and the tip is located
close to the anal verge?
In the last paragraph of this session beginning with HPZ all the formulas are calculated
automatically by the machine or it has to be done manually?
Results
It was good to know that the groups were homogeneous in age and BMI, however this
could be programmed and performed priorly, since the selection of patients were performed
prospectively. Why did you prefer to do it after? What if there was an heterogeneous
distribution?
2.2.2 - Authors find female age negatively related with maximum rest and squeezing pressure
in healthy women, but not in rectocele patients.
2.2.3 - how do authors explain linear logistic regression showing age as an independent factor
associated with worse maximum squeezing pressure in healthy and rectocele women
How did authors measure RAIR in the study? Water, air? How would you do together with the
rectal sensation test?
Why do authors use the word prognosis of many values found at the results, such as, maximum
squeezing pressure, age and RAIR? Would it be a diagnosis? Does it mean that the pressure, for
example, is lower in MRSW patients?
I think the large tables and the long texts with different variables and comparisons make the
results confusing? Could the authors rewrite and simplify the tables to make the results clearer?
For example, where is the logistic regression that shows that RAIR and age are independent risk
factors for the prognosis of MRSW? How do you get to this results? Also I have doubt about
what prognosis of MRSW means? Do the authors mean diagnosis of MRSW?
Discussion
How do you stratify the severity of the disease using HRAM?
I agree with your considerations regarding limitations of the study when you admit that
comparative studies with other image studies, such as 3D-US and RNM are necessary to have
this anatomical functional comparison.
What do you think were the main contributions of this study to the medical literature regarding
functional diseases of the colon and rectum? Would it change management of rectocele and
ODS from now on?
assistant