Protective Effect of an SDF-1 Variant in HIV Disease

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.