Review for 10.1186/s12876-025-04171-9 (2025)

Title: Clinical Relevance of Transperineal Ultrasound Compared with Anorectal Manometry
for the Evaluation of Female Patients with Obstructive Defecation Syndrome
Version: 0 Date: 13 May 2025
Reviewer:  Gonzalo Martin-Martin
Reviewer's report:
Feedback for the authors:
Thank you for the opportunity to review your manuscript entitled “Clinical relevance of
transperineal ultrasound compared with anorectal manometry for the evaluation of female
patients with obstructive defecation syndrome.” The topic addressed is relevant and timely,
particularly in the context of evaluating functional pelvic floor disorders, where non-invasive
diagnostic tools are gaining attention.
The manuscript presents a prospective comparative analysis between transperineal ultrasound
(TPUS) and anorectal manometry (ARM), aiming to evaluate their respective roles in the
diagnostic approach to obstructive defecation syndrome (ODS). The study is well-structured
and the objective is clearly defined. However, several aspects must be improved before the
manuscript can be considered for publication.
1. Methodological clarification:
Please provide more detail on the inclusion and exclusion criteria for participant selection. It
is important to clarify whether the diagnosis of ODS was based on established clinical criteria
such as the Rome IV or validated scoring systems.
Clarify whether a sample size calculation or power analysis was performed to support the
adequacy of the study population.
Define clearly the statistical approach used to assess the agreement between TPUS and ARM
findings.
2. Patient characterization:
The manuscript would benefit from a more detailed clinical profile of the patients, including
validated symptom severity scales such as the Wexner constipation score or the Constipation
Scoring System.
Indicate whether any of the patients had undergone prior treatments for pelvic floor dysfunction,
such as biofeedback or physical therapy.
3. Results interpretation:
Strengthen the correlation analysis between the clinical symptoms and the findings from both
diagnostic modalities.
If feasible, include subgroup comparisons (e.g., patients with rectocele vs. those without) to
better demonstrate the clinical value of TPUS.
4. Discussion depth:
Expand the discussion with references to current international guidelines and literature,
including the ASCRS clinical practice recommendations and the comprehensive insights
provided in Oliveira’s textbook on anorectal physiology.
A more critical discussion of the limitations of TPUS is needed, particularly regarding
operator dependency, image interpretation variability, and possible limitations in certain patient
subgroups (e.g., obesity, prior pelvic surgery).
5. Language and clarity:
Although the manuscript is mostly clear, a comprehensive language revision is recommended
to improve readability and grammatical precision.
Recommendation: Major revision
This manuscript addresses an important clinical question and has the potential to contribute
meaningfully to the literature. However, significant methodological and interpretative revisions
are needed to meet the scientific standards expected for publication in BMC Gastroenterology.