Margaret A.WinkerMD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Senior EditorIndividualAuthor
In Reply.—Dr Chai would like to retitle
the Clinical Crossroads article focused on management of BPH to indicate more
strongly that the lower urinary tract symptoms described by the patient, Mr
B, had not been proven definitely to be due to BPH. This suggestion is not
unreasonable, as the diagnostic uncertainty regarding the cause of such symptoms
in older men in general, and Mr B in particular, was indeed covered extensively
in the case discussion. One might quibble with Chai's contention that reducing
volume and decreasing outflow resistance are the only mechanisms by which
current treatments for BPH work to reduce symptoms. In fact, it has not been
demonstrated convincingly that the modest symptom reductions seen with finasteride
treatment are related to the reductions in prostate volume produced by this
therapy at the individual level (although prostate size at baseline is certainly
a predictor of symptomatic response). Moreover, as discussed in the article,
several of the newer device therapies, particularly transurethral microwave
thermotherapy and needle ablation, appear to reduce symptoms beyond what might
be expected in terms of any volume reduction or effect on outflow resistance.
Certainly a better understanding of the differential diagnosis of lower urinary
tract symptoms is important for clinicians. Further research is also necessary
to determine to what extent diagnostic "splitting" (as opposed to "lumping")
allows better selection of therapies and improved outcomes for men with lower
urinary tract symptoms suggestive of BPH.
Barry MJ. Protective Effect of an SDF-1 Variant in HIV Disease. JAMA. 1998;279(14):1070. doi:10-1001/pubs.JAMA-ISSN-0098-7484-279-14-jac80003
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