Background: Sildenafil is a commonly prescribed treatment for erectile dysfunction (ED), but its use has increasingly extended into recreational settings, particularly among young men. This shift raises public health concerns about misuse, unsupervised dosage, and associated side effects.

Objective: This study explored how people use sildenafil both for medical reasons and recreationally. It examined who uses it, how often, and why they take it, as well as the side effects they experience, especially when it is combined with alcohol.

Methods: A descriptive cross-sectional study was conducted from 1 December 2024 to 31 January 2025 in Prishtina, Republic of Kosovo. A self-administered questionnaire was distributed online and through pharmacies to men aged 18 years and older who had previously used sildenafil. The survey collected demographic information, reasons for use, frequency, dosage patterns, and reported side effects.

Results: A total of 91 male participants were included. Most were between 18 and 29 years of age (45%) and from urban areas (67%). The majority reported using sildenafil without a prescription (72%), with doses of 50 mg (48%) and 100 mg (44%) being the most common. Improving sexual activity (58%) and boosting self-esteem (18%) were the leading reasons for use. Only 13% used sildenafil to treat medically diagnosed ED. About 22% combined sildenafil with alcohol. Side effects such as headaches, low blood pressure, and vision disturbances were reported more frequently among recreational users. Regression analysis revealed a significant relationship between higher dosage and increased self-esteem, as well as a reduction in blood pressure.

Conclusion: Our findings indicate that many younger men are using sildenafil for recreational purposes, not solely for medical reasons. This kind of use is often associated with more side effects, possibly because doses are not properly regulated or sildenafil is taken alongside alcohol. These results underscore the need for enhanced public education on the safe use of sildenafil and more rigorous monitoring of non-prescription access to this medication.

alcohol interaction, erectile dysfunction, recreational use, self-esteem, sildenafil

Sildenafil is a phosphodiesterase-5 inhibitor (PDE-5i) used to treat erectile dysfunction (ED) and pulmonary arterial hypertension (PHT) (Saikia et al. 2022).

Erectile dysfunction is the result of a complex interaction between the neurological and vascular systems. Its underlying causes can be vascular, hormonal, neurogenic, iatrogenic, psychogenic, or a mix of these factors. It commonly appears together with other medical conditions and increases with age. The chances of developing ED are heightened with every passing decade after 40. Diabetes mellitus, hypercholesterolemia, depression, kidney failure, hypogonadism, and hypertension are chronic ailments linked with the condition (Lue 2000; Francis and Corbin 2005).

Approximately 150 million men worldwide have ED, and the use of PDE-5 inhibitors has steadily increased as a preferred first-line treatment. These medications promote vasodilation and can lead to mild reductions in blood pressure (Schwartz and Kloner 2010).

Sildenafil is highly effective when used appropriately, with its primary role being the treatment of male impotence. The medicine enhances the physiological erectile response during sexual stimulation but does not induce an erection on its own. Its ability to intensify and prolong erections has contributed to increasing off-label and self-directed use. This has raised concerns about the potential for inappropriate dosage and frequency without proper medical guidance (Marmor and Kessler 1999).

Improper use or abuse of sildenafil as a PDE-5i can lead to side effects such as headaches, facial flushing, indigestion, muscle aches, and visual disturbances (Lee et al. 2019).

An increasing number of studies point to a rising trend in the recreational use of sildenafil, especially among younger men, who often seek to enhance sexual satisfaction for both themselves and their partners rather than to treat diagnosed ED (Pomara et al. 2006; Atsbeha et al. 2021; Nazir et al. 2022).

The way ED is framed and diagnosed, combined with the easy accessibility and low cost of sildenafil, has contributed to its growing non-medical use. In recent years, recreational use, particularly in nightlife settings and often alongside substances such as mephedrone, ecstasy, cannabis, cocaine, and ketamine, has become more common. This trend, observed mainly among young men, appears to be driven by the desire to enhance erection rigidity, improve partner satisfaction, and increase sexual frequency (Smith and Romanelli 2005; Chan et al. 2015; Nazir et al. 2022).

Using sildenafil alongside nitrate-based blood pressure medications such as sublingual nitroglycerin or transdermal patches can lead to a dangerously rapid drop in blood pressure, which is why this combination is strongly discouraged (Ishikura et al. 2000).

Combining PDE-5 inhibitors with nitrates in patients who have coronary heart disease can significantly raise the risk of serious cardiovascular events, including both illness and death (Trolle Lagerros et al. 2024).

Recreational use of PDE-5 inhibitors alongside alcohol is becoming increasingly common worldwide. When taken together, the two substances can amplify both the frequency and intensity of side effects, especially those related to blood vessel dilation, such as facial flushing, headaches, nasal congestion, palpitations, and dizziness. Although many of these symptoms are mild, the combination has also been linked to more serious cardiovascular effects in some cases. This underscores the importance of informing users about the risks involved when mixing alcohol with these medications (Kim et al. 2019).

This study aims to examine the use of sildenafil for both therapeutic and recreational purposes, focusing on usage patterns, dosage, frequency, and side effects. It compares experiences between users treating ED and those using it for sexual enhancement or self-esteem. The study also explores the relationship between dosage and side effects, as well as the impact of combining sildenafil with alcohol.

Ninety-one participants participated in our study (see Table 1). All participants were sildenafil users. Most participants belonged to the 18–29 age group (45%), followed by the 30–39 age group (25%), the 40–49 age group (15%), the 50–59 age group (8%), and the 60 and over age group (6%). Most participants were from urban areas (67%), while others were from rural areas (23%).

Most participants reported using 50 mg (48%) or 100 mg (44%) as the most frequent sildenafil dosage. Similarly, most participants (44%) reported using 1–2 dosages, followed by 25% who reported using 3–5 dosages.

The most commonly reported reason for using sildenafil was to improve sexual activity (58%), followed by increasing self-esteem (18%), treating medically diagnosed erection problems (13%), and group pressure (11%). Participants from urban areas mainly reported using sildenafil to improve sexual activity (37%) and increase self-esteem (16%), while rural participants primarily cited improving sexual activity (21%) and treating erection problems (9%).

Regarding the source of purchase, the majority of participants (72%) reported obtaining sildenafil from a pharmacy without having a prescription. In comparison, 12% purchased it with a prescription, 9% obtained it online, and 7% from other sources. This pattern was consistent across both urban and rural groups, although urban participants had slightly higher online purchase rates (7%) than rural participants (2%).

The most frequently used dosages of sildenafil were 50 mg (48%) and 100 mg (44%), with smaller proportions using 200 mg (7%) and 300 mg (1%). Urban participants reported more frequent use of 50 mg (34%) and 100 mg (30%) dosages compared to rural users (14% for each). In terms of usage frequency, 44% of all participants reported using sildenafil 1–2 times, 25% had used it 3–5 times, 9% used it 6–10 times, and 22% reported using it more than 10 times.

When asked about the maximum dosage ever used, 33% reported 50 mg, 47% reported 100 mg, and 12% had used over 100 mg. A small number (8%) were not sure. Lastly, 22% of participants reported combining sildenafil with alcohol, while 71% said they did not, and 7% were unsure (see Table 2).

Next, we conducted a cross-tabulation to examine the number of dosages used by participants and the corresponding dosage amounts (see Table 3). Thirty percent of participants reported having used a 50 mg dosage 1–2 times, followed by 14% with 1–2 times and over 10 times.

We conducted an ANOVA to test the side effects of sildenafil use between participants. We found a significant impact on those who reported problems with blood pressure, F (3, 87) = 3.97, p = 0.011 (see Table 4). Post-hoc Bonferroni tests showed that participants who reported taking sildenafil for medical purposes also reported more blood pressure issues compared to those who reported taking it for increasing self-esteem.

Next, we conducted regression analysis to test the associations between sildenafil dosage and side effects reported by participants. We found a significant negative association between an increase in sildenafil dosage and blood pressure, B = –0.23, SE = 0.11, p = 0.03, and a positive association between sildenafil dosage and self-esteem, B = 0.23, SE = 0.25, p = 0.03.

These results suggest that individuals who consumed higher doses of sildenafil experienced lower blood pressure and higher self-esteem. Sildenafil dosage was not associated with higher heartbeat, B = –0.15, SE = 0.11, p = 0.15; vision problems, B = –0.16, SE = 0.07, p = 0.14; increase in energy and vitality, B = 0.15, SE = 0.18, p = 0.15; or sexual activity, B = 0.19, SE = 0.16, p = 0.07.

We also examined whether there was a difference in side effects among sildenafil users who combined it with alcohol and those who did not. We found that these two groups did not differ concerning headache, F (2, 88) = 2.02, p = 0.14; quick heartbeat, F (2, 88) = 1.22, p = 0.30; lower blood pressure, F (2, 88) = 0.88, p = 0.42; vision problems, F (2, 88) = 0.19, p = 0.83; sexual activity, F (2, 88) = 1.17, p = 0.31; or self-esteem, F (2, 88) = 1.02, p = 0.37. These results suggest that sildenafil usage combined with alcohol does not induce side effects different from those reported by users who did not combine sildenafil with alcohol.

This study aimed to explore patterns and consequences of sildenafil use among a sample of 91 participants, assessing demographic characteristics, dosing patterns, reasons for use, and side effects. The results provide valuable insights into the behaviors and experiences of individuals using sildenafil, with a particular focus on its recreational, non-therapeutic use.

The age distribution in our sample mirrors earlier research showing that younger men tend to use sildenafil not for treating medically diagnosed erectile dysfunction but rather to enhance sexual performance or satisfaction (Bechara et al. 2010).

Moreover, sildenafil use was more common among individuals from urban areas, possibly due to easier access and greater awareness – an association supported in other settings where patient understanding and availability have been shown to vary by location.

The high use of sildenafil in urban areas may also be attributed to the convenience of obtaining it from pharmacies, often without a formal medical prescription, as our findings suggest. This aligns with prior research indicating that easier access to pharmacies and over-the-counter (OTC) availability contribute to increased use in more urbanized settings (Li et al. 2024).

The dosage patterns observed in this study are consistent with typical prescribing practices for the treatment of erectile dysfunction (Lue 2000).

Differences in preferred dosages between urban and rural users may reflect variations in medical advice or health management practices, with urban users more exposed to pharmacies and information. In contrast, rural users may rely on more cautious approaches (Chen et al. 2019).

The primary reason for using sildenafil was to enhance sexual activity, supporting a previous study suggesting that sexual enhancement remains the primary motive for its use among non-clinical users (Atsbeha et al. 2021).

In our study, participants who reported using higher doses of sildenafil also reported higher self-esteem, suggesting that psychological benefits may accompany physical improvements. Although we did not directly measure spontaneity or sexual confidence, the association between dosage and self-esteem may reflect broader psychosocial effects of treatment. This is in line with the pathway model of sexual self-esteem, which proposes that PDE-5 inhibitors can indirectly enhance self-esteem by reducing performance anxiety and increasing perceived sexual control (Sontag et al. 2014).

Our data also showed that increased self-esteem was a common secondary reason for using sildenafil, highlighting its broader psychological impact. It is important to note that only a minority of participants reported using sildenafil to treat medically diagnosed erectile dysfunction, underscoring the widespread off-label use of the drug (Nazir et al. 2022).

This study assessed the adverse effects associated with sildenafil use, focusing on their prevalence and variation based on the purpose of use. The most commonly reported adverse effects were headache, rapid heartbeat, low blood pressure, and vision problems – findings consistent with previous clinical studies (Moreira et al. 2000).

A significant association was observed between sildenafil use for sexual activity enhancement and the experience of side effects such as headache, rapid heartbeat, and low blood pressure. This suggests that individuals using sildenafil recreationally may be at greater risk of adverse effects, potentially due to higher dosages, unsupervised use, or mixing with other substances. In contrast, those using sildenafil for medically diagnosed erectile dysfunction reported fewer side effects, likely reflecting more appropriate dosage and medical oversight (McMahon et al. 2000).

Interestingly, participants using sildenafil for sexual enhancement (non-medical use) reported a higher overall frequency of adverse effects, including headache, rapid heartbeat, and vision problems such as blurred vision or increased sensitivity to light. These findings are consistent with the existing literature, which shows that headaches occur in up to 28% of users and that visual disturbances, although less common, can persist for more than 24 hours in some cases (Atsbeha et al. 2021; Ausó et al. 2021).

This high profile of side effects among recreational users may be attributed to higher or inappropriate dosing and a lack of medical supervision. These results highlight the importance of monitoring sildenafil use, especially in non-clinical contexts where users may not be aware of the risks of the drug.

The uncertainty reported by some participants may indicate that sildenafil was occasionally taken unintentionally alongside alcohol, for example, during social drinking, or because participants could not recall the exact timing. This highlights a lack of awareness about the risks of mixing sildenafil with alcohol, especially in informal or everyday situations.

While some studies suggest that the use of sildenafil with low amounts of alcohol may not lead to significant adverse effects in healthy individuals (Leslie et al. 2004), other research has explored its use among alcohol-dependent men under medical supervision. For example, Grinshpoon et al. (2007) found that sildenafil not only improved erectile function but also enhanced quality of life without reporting serious cardiovascular events.

However, isolated case reports have documented serious complications, such as cerebral infarction, following the combined use of sildenafil and alcohol in individuals with no underlying conditions (Sipahioğlu et al. 2021).

This supports the hypothesis that alcohol may potentiate the hypotensive effects of sildenafil, thereby increasing the risk of acute vascular events in vulnerable cases.

Additionally, the interaction of alcohol with the gastrointestinal tract is well-known, as it can damage the gut mucosa (Rajendram and Preedy 2005).

Although some hypotheses suggest that PDE-5 inhibitors might have a protective effect against these damages, this has not been conclusively confirmed and requires further investigation (Duffin et al. 2008).

Therefore, the simultaneous use of sildenafil and alcohol remains a concerning issue, especially when there is no medical supervision or when the drug is used for recreational purposes. These findings underscore the need for increased education regarding the potential risks of this combination and for more cautious approaches, particularly among younger users and those using sildenafil off-label.

Many of the sildenafil users in this study came from the middle-income group. This might be because people in this group often have enough financial flexibility to purchase non-prescription medications but may not regularly seek or afford specialized medical care. As a result, they may choose to use sildenafil independently, as a way to enhance their sexual life or self-confidence, without necessarily consulting a doctor, based on the demographic and income trends observed in this study.

This study provides important insights into the non-clinical use of sildenafil, an area that has received relatively little attention in existing research. By exploring how the drug is used, why people choose to use it, and what side effects they experience, the study offers a well-rounded picture of both recreational and therapeutic use.

The combination of descriptive data and statistical analysis, including ANOVA and regression, adds depth and strength to the findings. Including comparisons between urban and rural participants also provides valuable context, helping to illustrate how geography and socioeconomic background may influence behavior. In addition, by examining factors such as self-esteem, the study sheds light on the psychological aspects of sildenafil use – an aspect often overlooked in more clinical discussions.

However, there are a few limitations worth noting. Because the study employed a cross-sectional design, it cannot establish cause-and-effect relationships, especially regarding how sildenafil may influence psychological or physical outcomes. The sample size was relatively small (91 participants) and skewed toward younger and urban users, which may limit the applicability of these findings to the broader population.

Additionally, since the data were self-reported, some responses may not be entirely accurate due to forgetfulness, misunderstanding, or a desire to provide socially acceptable answers. Finally, without clinical confirmation of any reported health conditions, the study cannot make strong medical claims about the effects of sildenafil.

The findings from this study shed light on the use of sildenafil, particularly in non-clinical settings. Many people are using sildenafil not for treating erectile dysfunction but rather for recreational purposes. It seems that recreational use is much more common than its use for medical reasons. This raises concerns about the potential for misuse, with individuals using the drug more than is necessary or appropriate.

However, since this study was cross-sectional, we cannot make conclusions about long-term effects. Further research is necessary to better understand the risks and benefits of using sildenafil outside its intended medical purpose.

Ultimately, while sildenafil is widely used, its primary purpose should remain the treatment of erectile dysfunction. The fact that many people are using it recreationally suggests a need for improved education about its safe use and the importance of seeking medical guidance. There is a risk that, if misused, the drug could cause harm, which makes awareness and responsible usage crucial.

Conflict of interest

The authors have declared that no competing interests exist.

Ethical statements

The authors declared that no clinical trials were used in the present study.

The authors declared that no experiments on humans or human tissues were performed for the present study.

The authors declared that no informed consent was obtained from the humans, donors or donors’ representatives participating in the study.

The authors declared that no experiments on animals were performed for the present study.

The authors declared that no commercially available immortalised human and animal cell lines were used in the present study.

Use of AI

No use of AI was reported.

Funding

No funding was reported.

Author contributions

DS and AB supervised this research project, had full access to the study data, and were responsible for ensuring the integrity of the data. DS, AB, and ZI contributed to the study design. GJZ and VQ provided instructions on the use of instruments for the outcome measures used in this study. ZI, AB, and GJZ contributed to the analysis and interpretation of the data. DS, AB, and VQ were responsible for manuscript preparation. AB and ZI performed the statistical analysis.

Author ORCIDs

Zana Ibraimi https://orcid.org/0000-0001-9761-8015

Adhurim Bresa https://orcid.org/0009-0007-4377-6908

Data availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request.