Title: Anorectal Manometry for the Diagnosis of Pelvic Floor Disorders in Patients with
Hypermobility Spectrum Disorders and Hypermobile Ehlers-Danlos Syndrome
Version: 2 Date: 21 Feb 2022
Reviewer:  Miriam Raquel Diniz Zanetti
Reviewer's report:
To authors:
Congratulations for the important and relevant study, which may contribute to improving HSD/
hEDS patients care. Bellow you will find my suggestions.
1- Please confirm the key-words, because I only found in the scientific database https://
decs.bvsalud.org/en/ths those: Ehlers Danlos Syndrome (EDS); psychosomatic disorders
METHODS
2- Squeeze pressures were obtained three times with 1 minute of rest in between. Each time, the
patient was asked to hold the squeeze for 20 seconds -How patients were instructed to do this
contraction. Was it possible for them to hold the contraction for 20 seconds or could they relax
and contract again during that period?
3- Balloon expulsion was performed using a non-latex rectal balloon (Mui Scientific,
Mississauga, ON, Canada) filled with 50 ml of water. -Were they already seated or did you first
introduce them in lateral decubitus and then position themselves sitting on a bedside commode?
4- All the examinations (High-Resolution Anorectal Manometry,  Balloon Expulsion Test (BET)
and MR Defecography) were performed on the same day? If so, one examination could not affect
the other? Were they in the same order, or it was randomly applied?
RESULTS
5- Table 1- including a history of vaginal delivery as a co-morbidity. As it is a physiological
event, I believe it should be mentioned in another way.
6- These results are also shown in table 2, I suggest it should not be on text. “Residual anal
pressures and paradoxical anal contraction at simulated defecation were higher in HSD/hEDS
patients, 73.8 mmHg vs 63.7 mmHg, p=0.030; 3% vs 8% relaxation, p=0.038, respectively. A
significantly more negative rectoanal pressure gradient was seen in HSD/hEDS (-40.3 vs -19,
p<0.001”. These data in the text were very repetitive because they are also presented in the table.
CONCLUSION
7- A good conclusion should answer at least the main objective of the study which was: “The
aim of the study was to compare clinical characteristics and anorectal pressure profile in patients
with HSD/hEDS to those of age and sex-matched patients without HSD/hEDS’. However, the
conclusion showed much more the importance of the HR-ARM exam than the characteristics
proposed on objective and found in the study. Please reformulate the conclusion answering the
main objective.
Title: Anorectal Manometry for the Diagnosis of Pelvic Floor Disorders in Patients with
Hypermobility Spectrum Disorders and Hypermobile Ehlers-Danlos Syndrome
Version: 2 Date: 21 Feb 2022
Reviewer:  Miriam Raquel Diniz Zanetti
Reviewer's report:
To authors:
Congratulations for the important and relevant study, which may contribute to improving HSD/
hEDS patients care. Bellow you will find my suggestions.
1- Please confirm the key-words, because I only found in the scientific database https://
decs.bvsalud.org/en/ths those: Ehlers Danlos Syndrome (EDS); psychosomatic disorders
METHODS
2- Squeeze pressures were obtained three times with 1 minute of rest in between. Each time, the
patient was asked to hold the squeeze for 20 seconds -How patients were instructed to do this
contraction. Was it possible for them to hold the contraction for 20 seconds or could they relax
and contract again during that period?
3- Balloon expulsion was performed using a non-latex rectal balloon (Mui Scientific,
Mississauga, ON, Canada) filled with 50 ml of water. -Were they already seated or did you first
introduce them in lateral decubitus and then position themselves sitting on a bedside commode?
4- All the examinations (High-Resolution Anorectal Manometry,  Balloon Expulsion Test (BET)
and MR Defecography) were performed on the same day? If so, one examination could not affect
the other? Were they in the same order, or it was randomly applied?
RESULTS
5- Table 1- including a history of vaginal delivery as a co-morbidity. As it is a physiological
event, I believe it should be mentioned in another way.
6- These results are also shown in table 2, I suggest it should not be on text. “Residual anal
pressures and paradoxical anal contraction at simulated defecation were higher in HSD/hEDS
patients, 73.8 mmHg vs 63.7 mmHg, p=0.030; 3% vs 8% relaxation, p=0.038, respectively. A
significantly more negative rectoanal pressure gradient was seen in HSD/hEDS (-40.3 vs -19,
p<0.001”. These data in the text were very repetitive because they are also presented in the table.
CONCLUSION
7- A good conclusion should answer at least the main objective of the study which was: “The
aim of the study was to compare clinical characteristics and anorectal pressure profile in patients
with HSD/hEDS to those of age and sex-matched patients without HSD/hEDS’. However, the
conclusion showed much more the importance of the HR-ARM exam than the characteristics
proposed on objective and found in the study. Please reformulate the conclusion answering the
main objective.
Please review this paper.
user
Title: Anorectal Manometry for the Diagnosis of Pelvic Floor Disorders in Patients with
Hypermobility Spectrum Disorders and Hypermobile Ehlers-Danlos Syndrome
Version: 2 Date: 21 Feb 2022
Reviewer:  Miriam Raquel Diniz Zanetti
Reviewer's report:
To authors:
Congratulations for the important and relevant study, which may contribute to improving HSD/
hEDS patients care. Bellow you will find my suggestions.
1- Please confirm the key-words, because I only found in the scientific database https://
decs.bvsalud.org/en/ths those: Ehlers Danlos Syndrome (EDS); psychosomatic disorders
METHODS
2- Squeeze pressures were obtained three times with 1 minute of rest in between. Each time, the
patient was asked to hold the squeeze for 20 seconds -How patients were instructed to do this
contraction. Was it possible for them to hold the contraction for 20 seconds or could they relax
and contract again during that period?
3- Balloon expulsion was performed using a non-latex rectal balloon (Mui Scientific,
Mississauga, ON, Canada) filled with 50 ml of water. -Were they already seated or did you first
introduce them in lateral decubitus and then position themselves sitting on a bedside commode?
4- All the examinations (High-Resolution Anorectal Manometry,  Balloon Expulsion Test (BET)
and MR Defecography) were performed on the same day? If so, one examination could not affect
the other? Were they in the same order, or it was randomly applied?
RESULTS
5- Table 1- including a history of vaginal delivery as a co-morbidity. As it is a physiological
event, I believe it should be mentioned in another way.
6- These results are also shown in table 2, I suggest it should not be on text. “Residual anal
pressures and paradoxical anal contraction at simulated defecation were higher in HSD/hEDS
patients, 73.8 mmHg vs 63.7 mmHg, p=0.030; 3% vs 8% relaxation, p=0.038, respectively. A
significantly more negative rectoanal pressure gradient was seen in HSD/hEDS (-40.3 vs -19,
p<0.001”. These data in the text were very repetitive because they are also presented in the table.
CONCLUSION
7- A good conclusion should answer at least the main objective of the study which was: “The
aim of the study was to compare clinical characteristics and anorectal pressure profile in patients
with HSD/hEDS to those of age and sex-matched patients without HSD/hEDS’. However, the
conclusion showed much more the importance of the HR-ARM exam than the characteristics
proposed on objective and found in the study. Please reformulate the conclusion answering the
main objective.
assistant