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Nicorandil‐induced penile ulcerations: a case series
Author(s) -
Yap Tet,
Philippou Prodromos,
Perry Matthew,
Lam Wayne,
Corbishley Cathy,
Watkin Nick
Publication year - 2011
Publication title -
bju international
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.773
H-Index - 148
eISSN - 1464-410X
pISSN - 1464-4096
DOI - 10.1111/j.1464-410x.2010.09463.x
Subject(s) - nicorandil , medicine , discontinuation , side effect (computer science) , penis , malignancy , angina , dermatology , pathogenesis , surgery , myocardial infarction , computer science , programming language
Study Type – Harm (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Nicorandil is used as a vasodilator for the prevention and long‐term treatment of angina. However, ulceration induced by nicorandil has been reported in the past, involving the mouth, anus and other parts of the gastrointestinal system. We herein report the largest to‐date series of external genitalia ulceration, related to treatment with nicorandil. OBJECTIVE To report on the largest series to date of ulceration of the external genitalia, related to treatment with nicorandil – a vasodilator for the prevention and long‐term treatment of angina – and to review the literature on the subject, focusing on the clinical features and the pathogenesis of this rare, yet marked, side‐effect. PATIENTS AND METHODS Three patients (aged 71–83 years) were referred for severe ulceration of the penis. A complete work‐up was performed to exclude potential underlying causes, including malignancy and sexually transmitted diseases. After a careful review of the patients’ medical history, a potentially causal relationship was noted; all patients had been taking nicorandil for at least 2 years before the development of penile ulceration. RESULTS Penile ulcers associated with nicorandil are characteristically large, deep, painful and have punched‐out edges. They usually involve the prepuce or the penile shaft skin. Higher doses of nicorandil (at least 40 mg daily) and surgical procedures seem to increase the risk for nicorandil‐related ulceration. Response to topical steroids is poor, but complete healing is achieved by discontinuation of nicorandil, while surgical treatment should be discouraged. CONCLUSION The growing body of literature showing the link between treatment with nicorandil and ulceration at multiple sites has led to the recognition of this side‐effect by the World Health Organization. Nicorandil‐related ulcers rarely involve the penile skin and constitute a diagnostic and therapeutic challenge. The pathogenesis of this rare side‐effect is largely unknown, but mechanisms such as the ‘vascular steal phenomenon’ and the direct toxic effect of the drug or its metabolites have been implicated.