Erectile dysfunction (ED) aka impotence is defined as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance [1]. It is a relatively common medical problem and is estimated to affect 322 million people worldwide, of whom 30 million live in Africa [2].

Phosphodiesterase 5 (PDE5) inhibitors such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra, Vivanza) are drugs approved by the United States Food and Drug Administration for the treatment of ED. Though these drugs are only approved for ED, many young healthy men use PDE5 inhibitors for sexual enhancement. Mounting evidence has identified a trend of recreational use of PDE5 inhibitors in combination with illicit drugs for sexual enhancement without medical indication [345]. Studies have identified several risk factors associated with PDE5 inhibitors, such as greater number of sexual partners, unprotected sexual relations, and sexually transmitted diseases [67].

In Ethiopia, alcohol, khat (Catha edulis), and tobacco are the most frequently used recreational substances and the rate of substance use is increasing, particularly in the younger population [8910]. Due to a lack of strong regulations, these PDE5 inhibitors can be easily accessed without prescriptions from pharmacies [11]. Although psychoactive substance use has become common practice among university students in Ethiopia, no studies have assessed the rate of PDE5 inhibitor use or its associated factors. Thus, we proposed to assess the prevalence of PDE5 inhibitor use and associated factors among University of Gondar (UOG) undergraduate students.

The response rate was 73.1% (n=418). Nearly nine-tenths of the respondents were single (89.4%, n=355) with a mean age of 21.9±1.88 years. More than two-thirds (69.4%, n=290) of the respondents were Orthodox Christians and from middle-income families (57.4%, n=240). One-third (30.6%, n=128) of student participants were in their second year of study and students from the Technology (27.5%, n=115), Health Sciences (26.3%, n=110), and Social Sciences (24.6%, n=103) campuses actively participated in the study. When asked about substance use, nearly six-tenths (58.9%, n=246) reported that they drink alcohol. Half of the respondents reported that they had engaged in sexual activity (50.7%, n=212) in the previous 6 months (Table 1).

Many population-based studies have reported the recreational use of PDE5 inhibitors among young men aged 18 to 44 years [451114]. Indeed, these drugs are approved for treating ED patients, but young healthy men may wish to use them to enhance their sexual performance. This use without indication can have an impact on sexual function, relationships with partners, and self-esteem. Moreover, very few studies have addressed the use of PDE5 inhibitors in students [3151617]. This is the first study reporting the prevalence of PDE5 inhibitor use among university students in Ethiopia.

Through this investigation, we identified that PDE5 inhibitors were used as a recreational drug by 5.5% of the participants, which is consistent with the study of Musacchio et al [18] (6%) conducted on college students in the United States. Although the prevalence of PDE5 inhibitor use here is comparably much lower than what was found in a Brazilian study [3], our findings may suggest that PDE5 inhibitor use by young male students is becoming a problem in Ethiopia. Our population reported that they used PDE5 inhibitors to enhance their sexual performance by improving erectile sensation and increasing penile rigidity. Similar to other studies, a high percentage (71.5%) of PDE5 inhibitor users liked to use them with alcohol and other illicit drugs [3181920]. More than half (56.5%) received these drugs from a friend, and they also reported that they can easily access PDE5 inhibitors as non-prescribed drugs. This unexpected risky behavior may lead to adverse consequences and such a finding necessitates further in-depth investigation to better understand these issues.

We used 2 standardized and validated questionnaires to investigate undergraduate students' sexual relationships, using the SEAR questionnaire and IIEF-15 to address their sexual confidence. The scores reflected overall good sexual relationship and confidence levels, with no pervasive ED. However, 30% of the sample exhibited a ≤50 score for sexual relationship, 20.3% had lower confidence levels, and nearly 45% reported a ≤60 score, indicating ED according to the SEAR. These findings were lower than those of previous studies conducted on medical students and young adult ED patients treating with sildenafil [2122]. Similarly, only 7.5% had ED according to IIEF-15. Our findings indicate a relatively high rate of severe ED in university students, which raises concerns. Previous studies indicated that underlying psychological problems were one of the predictive risk factors associated with severe ED in young men [2123]. Psychological issues have a particular impact on the wellbeing of both partners and more emphasis is needed on addressing psychological impediments in order to improve all aspects of sexual aspiration. The Global Better Sex Survey reported out of the 48% of young men with a degree of ED, 18% showed a prevalence of severe ED, but very few had taken a medication for ED [24]. This indicates that there is an unmet need to focus on sexual health, particularly in young men.

The transition from high school to college is a critical developmental period and a time when young men may engage in unprotected sex, especially those with many perceived health risk factors. PDE5 inhibitor drugs should be used only for ED under the direct supervision of healthcare providers. Illegal access to these drugs and concurrent use with potentially hazardous substances like alcohol or other illicit drugs might carry additional health risks. In this study, nearly two-thirds of PDE5 inhibitor users reported that they can easily obtain the drugs through a friend, from pharmacies without prescriptions, or from other sources. In addition, more than half of these drug users would like to use them again, which raises concerns about risky behavior in young students. With regards to substance use, cigarette smoking showed a statistically significant association with higher odds of recreational use of PDE5 inhibitors, more so than other substances (AOR, 5.15; 95% CI, 2.096~12.687). However in the study of Korkes et al [3], nearly three-fourths (71.4%) of young medical students mixed alcohol with PDE5 inhibitors. In binary logistic regression, recreational substance users were 3.4 times more likely to also use PDE5 inhibitors as compared to non-substance users. The recreational use of PDE5 inhibitors with other substances can have potentially serious side effects. Moreover, most of the PDE5 inhibitor users frequently reported side effects such as headache, blurred vision, longer duration of action, and dizziness; these side effects have also been reported in previous studies [3425].

We used 2 standardized SEAR and IIEF questionnaires with a cross-sectional study method to assess erectile function, sexual relationships, and confidence. Open-ended questions were limited in the questionnaire and the study was pilot-tested. In addition, PDE5 inhibitor use was tested using a different questionnaire to reduce recall bias.

However, the study is not without limitations. First, this study was cross-sectional and conducted at a single institution; therefore, the findings should be interpreted carefully when trying to establish a causal relationship. In addition, it may be difficult to generalize the findings to the whole body of undergraduate students studying at different universities in Ethiopia. Finally, data presented here is self-reported, and some of the participants may provide extreme responses as compared to others, according to the beliefs and motivations of the participants, which might be subject to recall bias.

The prevalence of PDE5 inhibitor use among undergraduate students was 5.5%. Cigarette smoking and other substance use, older age, and greater number of sexual partners were significantly associated factors for PDE5 inhibitor use. These findings suggest that restricting access to PDE5 inhibitor drugs is essential for curtailing misuse among university students. Further studies focusing on psychosocial determinants of ED and PDE5 inhibitor use in the younger population are warranted.