Usefulness of Transanal Irrigation and Colon Hydrotherapy in the Treatment of Chronic Constipation and Beyond: A Review with New Perspectives for Bio-Integrated Medicine

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Malformation and conditions such as spina bifida should be discussed

Colectomy as a therapeutic option is a dramatic step

 Line 306: Is it really:  simulate peristalsis?

TAI: There are multiple studies that partnered TAI with a multidisciplinary treatment approach in pediatric patients. I propose this concept should be mentioned

Freud: Most psychiatrist today are critical of Freuds concepts of the differrent phases. Perhaps this could be mentioned. 

Please comment what you mean by the term: Hysterical somatization! This is an offensive wording for women. Hysteros is the greek word for uterus, therefore this wording implies a negative connotation for women in general.

Line 714: For pediatric patients there are existing guidelines on the implementation of TAI

There are several systems such as Peristeen, Qufora and Navina smart that are available on the market. I propose these systems should be described.

 

Author Response

REVIEWER 1

• Malformation and conditions such as spina bifida should be discussed.

Thank you for your suggestion. An integration with relative new references has been added in discussion section.

 

• Colectomy as a therapeutic option is a dramatic step.

Although it is a dramatically invasive procedure, in some cases some recent guidelines also take into account the possibility of colectomy: “Surgical treatment CC treatment is mainly based on conservative measures; therefore, surgery will only be used for a limited number of patients. In clinical practice, surgery will only be considered when all conservative strategies have failed, such as in STC and distal constipation. The proposed surgical approaches include correctional interventions for pelvic floor disorders, colectomies (segmental and total), coloproctectomy and, more anecdotally, miniostomies (Malone procedure) and derivative stoma” (Vitton V, et al. Clinical practice guidelines from the French National Society of Coloproctology in treating chronic constipation. Eur J Gastroenterol Hepatol. 2018 Apr;30(4):357-363).

 

• Line 306: Is it really:  simulate peristalsis?

I apologize for the typo. It is “STIMULATE” peristalsis. Proper changes have been made.

In light of the intestinal neurophysiology and physiopathology considerations described in the background, it is indeed plausible that this sort of "passive exercise" characterized by repeated intestinal distensions and emptying in regular cycles, exerted gently but effectively by water pressure during TAI and especially CHT, can facilitate normal peristaltic activity, acting on intestinal mechanoreceptors and also eliminating fecal impaction and excess air.

 

• TAI: There are multiple studies that partnered TAI with a multidisciplinary treatment approach in pediatric patients. I propose this concept should be mentioned.

Appropriate references have been added to the discussion section, as suggested (see also point 1).

 

• Freud: Most psychiatrist today are critical of Freuds concepts of the different phases. Perhaps this could be mentioned. 

As suggested, it has been added a reference to the fact that many contemporary psychiatrists are critical of Freud’s theories and psychosexual stages. However, this criticism mainly concerns their literal and empirical validity. Freud did not intend these phases as rigid biological stages, but as dynamic organizations of libidinal energy shaping personality structure. His central claim—that early developmental experiences profoundly influence adult psychopathology—has been widely confirmed by modern developmental and attachment research. Thus, while empirically outdated, Freud’s theory retains conceptual and heuristic value when interpreted symbolically rather than literally.

 

• Please comment what you mean by the term: Hysterical somatization! This is an offensive wording for women. Hysteros is the greek word for uterus, therefore this wording implies a negative connotation for women in general.

The term “hysterical somatization” is employed in this context in its historical and psychodynamic sense, rather than in its obsolete gender-specific connotation. In contemporary psychosomatic and psychiatric literature, hysteria is understood as a nosological construct describing functional somatic symptom expression driven by unconscious psychological conflict, independent of sex or gender. Accordingly, the use of “hysterical somatization” in reference to gastrointestinal symptoms denotes a mechanism of symptom formation characterized by symbolic bodily expression, dissociation, and affective dysregulation, rather than a trait associated with women. The present usage therefore reflects a descriptive psychopathological model, not a gendered or pejorative characterization, and is applied equally across sexes in accordance with current understanding of somatization processes.

However, even if it remains conceptually useful in theoretical and psychodynamic discussion to describe specific modes of symptom organization, we gladly accept your suggestion to avoid possible misunderstandings and replace “hysterical somatization” with “Somatic Symptom Disorder”, according to more modern diagnostic frameworks for clinical classification (DSM-5-TR).

 

• Line 714: For pediatric patients there are existing guidelines on the implementation of TAI. There are several systems such as Peristeen, Qufora and Navina smart that are available on the market. I propose these systems should be described.

We have deliberately avoided making direct references to commercial products for ethical reasons and would prefer to continue along this line. However, following your suggestions, we implemented description of procedures and probes that can also be used in pediatric settings (see paragraph “3.3. TAI Classification”). We have also added more references to the benefits of TAI for pediatric use in the discussion section, as previously suggested (see point 1).

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

This is a very well written manuscript that reviews the evidence behind TAI and CHT in the treatment and prevention of chronic constipation and intestinal dysbiosis. The authors should be commended for providing in detail an explanation of how TAI and CHT work and how they may relate to relevant pathophysiology. 

A weakness of the manuscript is in describing the psycho-neuro-endocrinology-immunological framework (PNEI). This is only loosely described so there is no real coverage for example of the endocrine component of this model. Additionally Figure 5 is confusing as the model would be expected on first glance to show the 4 compartments above as delineated into Psychological/Neurological/Endocrine/Immunological but this is not the case. It is not at all clear the relevance of the 4 boxes in the top part of that figure - they seem to be a collection of different themes rather than a unifying model. 

Author Response

REVIEWER 2

• This is a very well written manuscript that reviews the evidence behind TAI and CHT in the treatment and prevention of chronic constipation and intestinal dysbiosis. The authors should be commended for providing in detail an explanation of how TAI and CHT work and how they may relate to relevant pathophysiology. 

Thank you for your appreciation of our work.

• A weakness of the manuscript is in describing the psycho-neuro-endocrinology-immunological framework (PNEI). This is only loosely described so there is no real coverage for example of the endocrine component of this model.

We thank the Reviewer for this comment regarding the apparently loose treatment of the PNEI framework and the limited explicit coverage of the endocrine component.

PNEI, although now formally recognized within the scientific literature, represents a relatively recent and rapidly expanding field characterized by highly complex, multidimensional, and interdisciplinary interactions. Providing a comprehensive and balanced account of all its components—particularly the endocrine pathways—would require a level of detail that goes beyond the scope and aims of the present manuscript.

Our primary objective in this work was not to deliver an exhaustive review of the PNEI model, but rather to introduce a novel interpretative perspective within the PNEI framework, specifically in relation to practices that remain underexplored or undervalued in contemporary research, such as TAI and CHT. In this context, the PNEI model is intentionally presented at a conceptual level, serving as a theoretical scaffold rather than as a fully detailed mechanistic description.

We are aware that a more extensive discussion, especially of the endocrine component, could further enrich the model; however, expanding this section substantially would significantly increase the length and complexity of the manuscript and potentially shift its focus away from its main conceptual contribution. For these reasons, we opted for a concise and integrative presentation, emphasizing coherence and readability.

Future targeted studies will be essential to deepen and refine the understanding of PNEI and all the specific mechanisms involved. We therefore view the present work as a starting point intended to stimulate further empirical and theoretical investigation rather than as a definitive account of all PNEI components.

 

• Additionally Figure 5 is confusing as the model would be expected on first glance to show the 4 compartments above as delineated into Psychological /Neurological /Endocrine /Immunological but this is not the case. It is not at all clear the relevance of the 4 boxes in the top part of that figure - they seem to be a collection of different themes rather than a unifying model.

We thank the Reviewer for this thoughtful comment, which allows us to better clarify the rationale of Figure 5. The aim of Figure 5 was not to provide a rigid compartmentalization of the PNEI system into strictly separated Psychological, Neurological, Endocrine, and Immunological domains, but rather to illustrate the intrinsic overlap and multi-directional interactions among these components.

PNEI, by its very nature, represents a highly complex and integrative framework, in which psychological processes, neural circuits, endocrine signaling and immune responses are deeply interconnected and often functionally inseparable. For this reason, a strictly delineated visual separation into four independent compartments can result misleading, as it might imply a degree of independence that does not reflect current scientific understanding. The four boxes in the upper part of Figure 5 are only a design choice intended to represent intersecting thematic domains rather than isolated systems. Moreover, their partial conceptual overlap, aimed at emphasizing the multidimensional and multidisciplinary nature of PNEI, can be considered a strength rather than a limitation of the model. Furthermore, many key mediators (e.g., cytokines, neurotransmitters, neuropeptides, hormones) simultaneously belong to more than one domain. Attempting to assign them visually to a single compartment would inevitably oversimplify their role.

That said, we acknowledge that the current version of the figure may benefit from additional clarification. To address this point, we have expanded the figure legend to explicitly state that the boxes represent overlapping conceptual domains rather than discrete compartments. We believe that, with these clarifications, Figure 5 more accurately conveys the integrative and systemic perspective that characterizes PNEI.

Author Response File: Author Response.docx