Erectile Dysfunction on Organic Nitrates or Nicorandil: When First-Line Treatments Have Not Worked
Clinical scenario
Men with erectile dysfunction who concurrently use organic nitrates, nicorandil, or other nitric oxide donors — including recreational use of amyl nitrite or nitrate — face an absolute contraindication to PDE5 inhibitors. Nicorandil carries the same restriction owing to its nitric oxide-donating properties, which can increase cGMP levels. Management must therefore rely on non-PDE5I approaches, and when those fall short, a further step is indicated.
Previous treatment — goal not reached
The following first-line non-PDE5I interventions were attempted:
- Lifestyle modifications: physical activity, weight loss, cardiovascular risk factor management
- Intracavernous alprostadil
- Intracavernous Trimix (papaverine + phentolamine + alprostadil)
- Invicorp (vasoactive intestinal peptide + phentolamine mesylate, intracavernous)
- Topical alprostadil applied to the urethral meatus
- Intraurethral alprostadil
- Vacuum erection device
This protocol applies when those measures did not achieve an erection with rigidity sufficient for satisfactory intercourse.
Next clinical step — partial overview
At this stage, the clinical pathway involves a surgical intervention to restore function. The full indication criteria, patient selection considerations, and device guidance are detailed in the structured protocol.
Treatment goal
Restoration of penile erection sufficient for satisfactory intercourse.
References
- An absolute contraindication to PDE5Is is the concomitant use of any form of organic nitrate or nitric oxide donors, including recreational use of amyl nitrite or nitrate (poppers).
- Concurrent use of nicorandil and PDE5Is is contraindicated due to the potential of the nitric oxide donating properties of nicorandil to increase cGMP levels.
- Implant a penile prosthesis if other treatments fail or depending upon patient preference.
- The surgical implantation of a penile prosthesis may be considered in patients who i) are not suitable for different pharmacotherapies or prefer a definitive therapy; and, ii) do not respond to other treatment modalities.
- The two currently available classes of penile implants include inflatable (two- and three-piece) and semi-rigid devices (malleable, mechanical and soft flexible).
- Efficacy is defined as an erection, with rigidity, sufficient for satisfactory intercourse.
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