Beyond erectile dysfunction: recreational use of PDE5 inhibitors among men who have sex with men—a systematic review and meta-analysis

Introduction: Phosphodiesterase type 5 inhibitors (PDE5i) are increasingly used beyond the treatment of erectile dysfunction, including for non-medical, performance-oriented purposes among men who have sex with men (MSM). This study aimed to systematically review the literature and meta-analyze the prevalence of recreational or non-medical PDE5i use among MSM and to explore potential sources of between-study heterogeneity. Methods: A systematic review and meta-analysis of observational studies was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, Scopus, Cochrane Library, and Web of Science were searched from inception to March 2026. Studies reporting quantitative estimates of recreational, non-prescribed, or general PDE5i use among MSM were included. Pooled prevalence estimates were calculated using random-effects meta-analysis of proportions with logit transformation. Sensitivity analyses, subgroup analyses, and assessment of small-study effects using the Doi plot and Luis Furuya-Kanamori index were performed. Results: Five cross-sectional studies including 4390 MSM met the eligibility criteria. Reported prevalence ranged from 16.1% to 53.6%. The pooled prevalence of PDE5i use was 24.4% (95% CI, 16.7%-34.2%; I2 = 97.1%). Exclusion of the main outlier reduced the pooled estimate to 19.1% (95% CI, 17.0%-21.4%; I2 = 62.3%). Prevalence was higher in venue-based than community-based samples (32.4% vs. 19.9%) and in studies with a 6-month compared with a 3-month recall period (21.2% vs. 16.8%). The Luis Furuya-Kanamori index (2.43) suggested major asymmetry, consistent with possible small-study effects. Discussion: Recreational or non-medical PDE5i use appears common among MSM, affecting approximately one in four individuals overall and approximately one in five after exclusion of the main methodological outlier. Although this represents the first systematic review and meta-analysis addressing this topic, interpretation is limited by the small number of available studies, their cross-sectional design, reliance on convenience sampling, heterogeneous outcome definitions, and substantial between-study heterogeneity. These findings support routine clinical assessment of recreational PDE5i use among MSM, particularly in the context of concomitant illicit drug use, and highlight the need for standardized definitions and more robust epidemiological research.