Introduction
Erectile dysfunction (ED) is a subject that simultaneously carries enormous clinical significance and a weight of cultural stigma. Defined as the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance, ED is not a trivial disorder. It is a condition intricately linked to vascular, neurological, hormonal, and psychological pathways. It is also a sensitive social issue that affects self-esteem, marital harmony, and overall quality of life.
In developing nations such as India, ED has remained underreported for decades, not because of low prevalence, but because of silence—patients hesitate to seek care, and physicians often fail to initiate conversation. Yet, the demand for treatment has increased steadily, driven by greater awareness, the influence of media, and the widespread availability of PDE5 inhibitors such as sildenafil (Viagra).
A hospital-based cross-sectional study conducted in India and published in the Journal of Clinical and Diagnostic Research (2015) provides crucial insights into how ED presents in clinical practice, how commonly it occurs, and how it is managed with pharmacological interventions. By carefully examining prevalence data and prescription patterns, the study allows us to better understand both the promise and pitfalls of ED management in resource-limited settings.
The Burden of Erectile Dysfunction in India
Prevalence data from the study confirm that ED is a common complaint among middle-aged and elderly Indian men. More than 60% of patients attending the outpatient urology clinics were found to have some degree of ED, ranging from mild to severe forms. This figure aligns with global estimates, which suggest that ED affects nearly 50% of men above the age of 40.
Age was, unsurprisingly, a strong determinant. Prevalence increased steadily with each decade of life. Men between 30–40 years frequently presented with mild, situational ED, while those above 50 exhibited more severe and persistent dysfunction. The role of comorbidities—particularly diabetes mellitus, hypertension, and ischemic heart disease—was strikingly evident. Nearly half of the men with ED in this study carried at least one significant systemic illness, suggesting that ED serves as a clinical red flag for broader vascular health.
Cultural context cannot be ignored. Many men delayed seeking help until symptoms became chronic, often after unsuccessful attempts at self-medication with over-the-counter PDE5 inhibitors purchased without prescriptions. This behavior highlights both the desperation of patients and the gaps in regulatory oversight.
Clinical Evaluation and Diagnostic Patterns
Evaluation of ED in this cohort often began with a detailed history rather than sophisticated diagnostic tools. Physicians emphasized:
- Onset, duration, and severity of erectile problems.
- Presence of nocturnal or early-morning erections (helping to differentiate psychogenic from organic ED).
- Past or concurrent use of medications such as antidepressants or antihypertensives.
- Comorbid diseases, especially diabetes and cardiovascular pathology.
Objective tools such as the International Index of Erectile Function (IIEF-5) were occasionally used but not universally applied. This reflects the reality in many resource-limited settings: reliance on clinical history, with limited deployment of validated questionnaires or invasive diagnostics like penile Doppler ultrasound.
Prescribing Trends: PDE5 Inhibitors at the Center
Sildenafil: The Pioneer and Mainstay
Sildenafil citrate, the first oral PDE5 inhibitor, was by far the most prescribed medication. It accounted for nearly 70% of all prescriptions in the study cohort. The reasons were clear: low cost, widespread availability, and physician familiarity.
Patients often received sildenafil in dosages ranging between 50–100 mg, typically taken one hour before intercourse. Most reported satisfactory improvement in erectile function. Side effects—headache, flushing, and dyspepsia—were observed but rarely led to discontinuation.
Tadalafil: The Challenger with Longer Duration
Tadalafil, a longer-acting PDE5 inhibitor with a half-life of 17.5 hours, represented about 20% of prescriptions. It was particularly favored for men who desired spontaneity rather than scheduled intercourse, since its duration of action could last up to 36 hours. Moreover, tadalafil showed added benefits in relieving lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH).
However, the higher cost compared to sildenafil restricted its use in lower-income populations. Physicians reserved tadalafil for patients who either failed sildenafil or requested longer-duration coverage.
Other Agents: Udenafil, Dapoxetine, and Combination Use
Less commonly, drugs such as udenafil and avanafil appeared in prescriptions, though usually in urban centers with more affluent patient populations. Dapoxetine, a short-acting SSRI, was sometimes co-prescribed in men suffering from both premature ejaculation and ED—a dual condition not uncommon in younger patients.
Combination therapies were employed in selected cases, often pairing sildenafil with testosterone supplementation in hypogonadal men, or dapoxetine in those with coexisting ejaculatory disorders.
Patterns of Use and Misuse
One of the most concerning findings of the study was the prevalence of self-medication. Many patients had already experimented with PDE5 inhibitors purchased without prescription from local pharmacies before consulting a physician. This practice carried multiple risks:
- Incorrect dosing, leading to either therapeutic failure or exaggerated side effects.
- Use in contraindicated settings, such as in men taking nitrates, risking catastrophic hypotension.
- Psychological dependence, where men began to fear intercourse without pharmacological assistance.
Moreover, there was minimal structured follow-up. Few patients underwent regular monitoring of cardiovascular status after initiating therapy, even though ED itself should prompt cardiovascular risk evaluation.
The Role of Testosterone in Indian Practice
Though PDE5 inhibitors dominated prescriptions, testosterone therapy emerged as an adjunct in cases of hypogonadism. Men with low serum testosterone, reduced libido, and metabolic comorbidities were occasionally prescribed injectable or transdermal testosterone in combination with PDE5 inhibitors.
Results were mixed. While some patients experienced enhanced libido and erectile quality, others discontinued therapy due to cost, inconvenience, or fear of side effects such as prostate cancer—a concern more rooted in perception than in robust clinical evidence.
Testosterone was never used as a standalone therapy for ED; it was consistently prescribed as part of a combination strategy when laboratory evidence of deficiency existed.
Patient Outcomes and Satisfaction
Overall, patient satisfaction was relatively high, especially among first-time users of PDE5 inhibitors. Most men reported improvement in confidence, marital harmony, and sexual performance. Interestingly, the psychological benefit often exceeded the measurable improvement in erection scores, underscoring the powerful placebo and reassurance effects inherent to ED management.
However, long-term adherence was less encouraging. Many patients discontinued medications after initial use, citing cost, side effects, or diminished novelty. Others shifted from prescribed therapy to over-the-counter purchase once they learned the drug name and dose.
This behavioral pattern reflects the intersection of medical management and socioeconomic constraints in India—an environment where affordability and accessibility often dictate long-term treatment strategies more than clinical guidelines.
Clinical Implications for Indian Urology
The findings of this study carry several important clinical lessons:
First, ED is common and frequently coexists with systemic illnesses. Every man presenting with ED deserves a comprehensive cardiovascular and metabolic evaluation. Treating ED in isolation risks overlooking underlying disease.
Second, PDE5 inhibitors remain the cornerstone of therapy, but their rational use requires physician guidance. Education of both prescribers and patients is necessary to curb misuse.
Third, combination strategies—PDE5 inhibitors with testosterone or dapoxetine—are valuable in specific subgroups and should not be overlooked in clinical practice.
Finally, counseling remains as important as pharmacology. Addressing anxiety, marital tension, and unrealistic expectations can determine therapeutic success more than milligram adjustments.
Limitations of the Current Evidence
The study, though insightful, had limitations. Being hospital-based, it likely underrepresented rural populations where healthcare access is limited and cultural barriers are higher. Reliance on prescription records meant that long-term adherence and outcomes were not fully captured. Moreover, absence of standardized diagnostic scales like IIEF-5 in all patients limited comparability with global studies.
Nevertheless, the study remains a valuable lens through which we can view ED management in India, highlighting both achievements and deficiencies in real-world practice.
Conclusion
Erectile dysfunction in India is neither rare nor trivial. It affects a majority of middle-aged and elderly men, often signaling broader systemic disease. Yet, cultural stigma and widespread self-medication obscure its true burden.
PDE5 inhibitors, especially sildenafil and tadalafil, dominate prescribing patterns, offering reliable efficacy and relative safety when used under medical supervision. Testosterone and combination therapies serve as useful adjuncts in select groups.
The central challenge is not the absence of effective drugs but rather their rational use. Misuse, lack of follow-up, and affordability constraints undermine optimal outcomes. Moving forward, the solution lies in combining pharmacological therapy with patient education, cardiovascular screening, and destigmatization of sexual health.
In a society where silence has long been the norm, simply opening the conversation about ED is as therapeutic as any pill.
FAQ
1. Why is sildenafil prescribed more commonly than tadalafil in India?
Sildenafil is cheaper, widely available, and familiar to physicians. While tadalafil offers longer action, its higher cost limits widespread use.
2. Can ED medications be taken without a prescription?
In India, many men purchase PDE5 inhibitors over-the-counter. However, this is unsafe due to potential drug interactions (especially with nitrates) and risk of incorrect dosing. Medical supervision is strongly recommended.
3. Is testosterone useful for erectile dysfunction?
Testosterone is helpful in men with proven hypogonadism, usually in combination with PDE5 inhibitors. It is not effective as a standalone treatment for ED in otherwise eugonadal men.
