In an analysis of microbial loads of various illicit ED drugs, 23% were contaminated with more than 103 colony-forming units (CFU), and 69% had elevated levels considered within acceptable limits. Furthermore, the manufacturing conditions of counterfeiters cannot match the sterile processing conditions of legitimate pharmaceuticals. Counterfeiters do not declare these ingredients or warnings of possible deleterious interactions on their packaging. Non-declared pharmaceuticals can have drug interactions and side effects such as gastrointestinal symptoms and nausea when combining metronidazole and alcohol. These are used either as bulking agents to lower production costs or to imitate the appearance and physical qualities of the genuine product. The large market for counterfeit medications is not equally distributed in size or class of medications worldwide. Some sources estimate that the market for counterfeit medications ranges between 75 and 200 billion dollars (5,6). In addition to the intellectual property rights that counterfeiters violate, the products they make can place consumers in danger. This can include products with bona fide ingredients, but with insufficient or excessive quantities, products with the wrong ingredients, or products with deceptive packaging. This communication reviews the literature regarding counterfeit PDE-5i, and summarizes both the scope and dangers of the illicit PDE-5i market. With ProflexiaRX, you’ll obtain all the muscle-building benefits that you require without any adverse effects. This natural supplement enhances testosterone levels for a more powerful, extra muscular body. So if you’re looking for a supplement that can aid renew your sensuous life and also restore balance, look no more than Proflexia. Surgery is typically reserved for men whose penises don't work because of a problem present at birth or an injury. But it does not change the actual length of the penis. Or surgery may add a slight appearance of increased length to the non-erect penis. At best, surgery may give a slight increase in girth to the penis. Fuel groundbreaking medical research! But, there's little scientific support for nonsurgical methods to enlarge the penis. Many pumps, pills, weights, exercises and surgeries claim to increase the length and width of your penis. After one month of discharge patient’s condition did not returned to baseline. During his hospital stay, it was determined that the patient had suffered a CVA. In the ER patient had seizure like activity for which he was given 1 g of Dilantin and Ativan. Unfortunately, patient took several different brands of ED pills at the same time, assuming its “safe” as proclaimed on the packaging. Per patient “I was not aware of the contents in neither the ED pills nor the substances contained within it”. The patient reported that he went to bed at 10 pm after taking his insulin (25 units) without checking his blood sugar. Generally, individuals have had positive experiences with using this product.However, taking illicit PDE-5i may harm consumers directly, as many illicit products contain detrimental contaminants and inaccurate amounts of the active ingredient without the appropriate warnings.These non FDA approved products with unknown ingredients are widely accessible for purchase ranging from local food, drug stores and to the internet.The counterfeit drug market is a nebulous and constantly evolving entity that has become increasingly difficult to define and quantify.This supplement features a complimentary trial, so make certain to take it prior to starting your Male Enhancement program.Consumer request has created a huge demand for these products and has led to sales in the hundreds of million to billions of dollars in the US and world-wide 1,3 Walgreens Prostate Health Advanced Caplets (30 days) (Packaging May Vary) - 60 ea Many “natural supplements” contain illicit PDE-5i, subjecting users to the same risks with even less warning.If your penis is about 5 inches (13 cm) or longer when erect, it's of typical size.So if you’re looking for a supplement that can aid renew your sensuous life and also restore balance, look no more than Proflexia.These results are not surprising, when considering the strict regulations and inspections that legitimate pharmaceutical producers must pass, compared with the unsterile conditions in which counterfeiters may work.Increasing household income and availability of a sexual partner positively correlate with their legal use (15).Companies offer many types of nonsurgical penis-enlargement treatments.These products keep the consumer in the dark in terms of the quantity, ingredients, effectiveness and possible side effects.These are used either as bulking agents to lower production costs or to imitate the appearance and physical qualities of the genuine product. Physicians who treat ED should warn patients against purchasing PDE-5i via alternative means, especially the Internet. By bypassing the legitimate healthcare system, users of counterfeit PDE-5i bypass screening for concurrent medical comorbidities, as well as proper education and warnings of PDE-5i use. Patients embarrassed by their condition or seeking less expensive alternatives to legitimate pharmaceuticals have fueled the market, and the growth of Internet pharmaceuticals have made counterfeit pharmaceuticals easy to obtain. As the population ages, and the market for PDE-5i grow, so does the illicit market for PDE-5i. These products come in a liquid form and a tablet form that help men struggling with a healthy sex life. The count will be inaccurate when sponsored products are displayed, when multiple sizes or colors of a product are grouped on a single product card, and when the in-stock filter is applied. The number of tablets found inside of the bottles and the prices of the supplements may also influence your decision. Taking the time to read the product descriptions can help you identify the formulas that are geared toward addressing your specific sexual concerns. Sexual enhancement tablets may also contain nutrients that some scientists believe may play a role in arousal and sexual performance. But there are a few things you can do if you're concerned about your penis size. There's no guaranteed safe and proven way to enlarge your penis. When the suspensory ligament is cut, the non-erect penis may look longer because more of it hangs outside the body. Some surgeons offer cosmetic penis enlargement using many techniques. This safe and also effective supplement is scientifically proven to helpenhance s3xual efficiency as well as stamina. Generally, individuals have had positive experiences with using this product. Some individuals speak highly of the supplement, declaring that it functions wonders for them. Remember that any type of product, whether it is a Male Enhancement or not, need to be made use of with caution and under medical supervision. It consists of medically tested ingredients that work together to boost muscle mass growth. This item is made to help increase testosterone levels in the body, which is essential for total male health and wellness and well-being. Are you seeking ProflexiaRX Male Enhancement supplement that truly functions? Are you looking for a Male Enhancement supplement that utilizes reducing side science to assist you Male Enhancement swiftly? With this powerful Male Enhancement supplement, you’ll get on your way to achieving your Male Enhancement dreams in a snap! This supplement features a complimentary trial, so make certain to take it prior to starting your Male Enhancement program. Perhaps even more dangerous than the counterfeit PDE-5i that is marketed as legitimate pharmaceuticals, however, are those marketed as “natural” supplements.By bypassing the legitimate healthcare system, users of counterfeit PDE-5i bypass screening for concurrent medical comorbidities, as well as proper education and warnings of PDE-5i use.Ads for penis-enlargement products and procedures are everywhere.Remember that any type of product, whether it is a Male Enhancement or not, need to be made use of with caution and under medical supervision.So manufacturers don't have to prove how safe a product is or that it works.Sexual enhancement tablets may also contain nutrients that some scientists believe may play a role in arousal and sexual performance.Many manufacturers market the products as dietary supplements because the products contain natural ingredients, including vitamins and minerals. The common link between these patients was the use of an ED supplement that contained glyburide (a sulfonylurea used to treat diabetes), as well as illicit PDE-5i (31). Perhaps even more dangerous than the counterfeit PDE-5i that is marketed as legitimate pharmaceuticals, however, are those marketed as “natural” supplements. Of these users, 68% did so without a prescription, as patients often do not realize that they are getting false and possibly dangerous products, and 60% of these users believed they received the same product as from a legitimate pharmacy (13). Regardless of the definition, drug counterfeiting has become a global problem. Furthermore, PDE-5i can have potentially dangerous interactions with other pharmaceuticals that are rarely warned against with counterfeit PDE-5i. Others seek to bypass the legitimate healthcare system due to either embarrassment of the underlying condition or desire for cheaper alternatives. Already in widespread use, the market for PDE-5i is steadily growing as the population ages. Many men also have an exaggerated idea of what is considered a "typical" penis size. But most men who think their penises are too small actually have penises that are considered typical size. The fear that your penis looks too small or is too small to satisfy your partner during sex is common. And no trusted medical organization endorses penis surgery for purely cosmetic reasons. However, taking illicit PDE-5i may harm consumers directly, as many illicit products contain detrimental contaminants and inaccurate amounts of the active ingredient without the appropriate warnings. Many factors are contributing to the rapid growth of the illicit market, such as the low risk of prosecution, potentially high financial reward, and ease of distribution via Internet pharmacies. And these products may have potentially dangerous ingredients not listed on the label. Ads for penis-enlargement products and procedures are everywhere. Physician should have low threshold in prescribing for erectile dysfunction medication and to carefully monitor patients who are at risk of developing ED in the future to encourage more open conversation about this topic and eliminate the stigma of ED. The FDA has identified more than 350 different supplements marketed for sexual enhancement and found to be tainted with prescription medication of which the quality and quantity is questionable due to lack of oversight in these products. We present a case report of an individual with bipolar disorder and hypersexual behavior who became victim to over the counter sexual enhancement products/supplements which caused serious health and life threatening consequences. Safety and quality concerns regarding over the counter sexual enhancement products sold in the USA market pose a major health risk to the general public. As you consider the options available to help you promote a more satisfying sex life with dietary supplements, you'll want to carefully compare products. Many “natural supplements” contain illicit PDE-5i, subjecting users to the same risks with even less warning. Furthermore, counterfeit PDE-5i often contain improper dosing and contaminants that may place patients at direct risk. Strategies to limit counterfeiting should be multi-faceted and target prescribing healthcare professionals, pharmaceutical companies, regulatory authorities, and patients. Hombron Natural Male Enhancement Tablets - 60 Each Unfortunately, as reported by patient he went home after discharged and he continued to abuse ED supplements. To list some of these products which the patient took, as confirmed by patient, included “Male Enhancement”, “Extenze” which had the word written “doctor approved”. As in the majority of these cases, the manufactures of these products neither list the true content and nature of the ingredients nor indicate the quantity or quality of the substances used in these products . Inadequate regulatory measures, weak quality control system and uncontrolled distribution by various vendors are some of the reasons that has augmented herbal supplements market . These products keep the consumer in the dark in terms of the quantity, ingredients, effectiveness and possible side effects. These non FDA approved products with unknown ingredients are widely accessible for purchase ranging from local food, drug stores and to the internet. When shopping for male enhancement products, read the label carefully. Walgreens.com offers male enhancement products from well-known brands as ExtenZe and Nugenix. In Indonesia, 100% of “Viagra” sold by street peddlers, 56% purchased in “drug stores”, and 13% acquired from legitimate pharmacies was counterfeit Viagra marked as authentic (29). Similar results were found in an analysis of counterfeit ED drugs sold in Italy, Austria, and Canada (28). The concentration of active sildenafil ranged from 0–200% of indicated strength, and only 10% of the samples contained an active ingredient within 10% of what was advertised on the packaging (27). Strict guideline and regulations for erectile dysfunction supplements should be implemented to prevent misuse of medications such as Sildenafil or Tadalafil or medications similar in structure. Concrete steps must be taken to improve the safety and well-being of consumers and to decrease the health related consequences from those products which should only be taken under the advice of a physician. Nevertheless, FDA faces serious obstacles in identifying these products true ingredients in a timely fashion to prevent physical damage being done to general public. It was concluded by the psychiatric treatment team that the patient’s physical state/seizures like activity was resulting from his continued misuse of over-the counter- ED supplements as self-reported by patient and his friend. Some products are designed to improve sexual performance by enhancing arousal to promote firmer erections or to help intercourse last for longer periods of time. Sexual enhancement tablets are a type of dietary supplement that is taken by mouth with the goal of improving sexual experiences. Walgreens has an assortment of sexual enhancement tablets available to meet your needs and will ensure that your order is shipped discreetly to your door. If you're struggling to feel confident and in control during intimate moments, sexual enhancement tablets may help to improve your experiences and deepen your satisfaction. However, by doing so, many of these patients are unknowingly subjecting themselves to significant health dangers. During his hospital stay, it was determined that the patient had suffered a CVA.The FDA has identified more than 350 different supplements marketed for sexual enhancement and found to be tainted with prescription medication of which the quality and quantity is questionable due to lack of oversight in these products.Understanding your partner's needs and desires is more likely to improve your sexual relationship than changing the size of your penis.Similar results were found in an analysis of counterfeit ED drugs sold in Italy, Austria, and Canada (28).It is largest in poor and developing countries, with the size of the market being inversely proportional to the amount of regulation.Between 2004 and 2008, 35.8 million counterfeit sildenafil tablets were seized in Europe, which is 7 times greater than the amount of all other counterfeited Pfizer products combined.In fact, for PDE-5i, the illegal market in industrialized countries approaches the size of that in developing countries. Medical Professionals Oftentimes, these ingredients include herbs that have a history of use as aphrodisiacs or folk treatments for impotence (inability to achieve or maintain an erection). Every man wants to perform at his best in the bedroom and can suffer when sexual problems stand in his way. In addition to its many advantages, Proflexia RX is also safe to use as well as has no reported adverse effects. Are you seeking a Male Enhancement supplement that can help you Male Enhancement swiftly? In addition, there is a great deal of complication bordering this supplement, so its crucial to be equipped with the realities. Plus, there are no known side effects related to utilizing it. Looking for a Male Enhancement supplement that is risk-free and efficient?The patient reported that he went to bed at 10 pm after taking his insulin (25 units) without checking his blood sugar.There are numerous known side effects of PDE-5i, some of which may be life threatening.Or surgery may add a slight appearance of increased length to the non-erect penis.There are also lots of negative effects connected with using this supplement, consisting of anxiousness, sleep loss, as well as exhaustion.Furthermore, counterfeit PDE-5i often contain improper dosing and contaminants that may place patients at direct risk. Ultimately, we’ll likewise be giving you an advising regarding some prospective side effects that might take place while using it. Lots of people across the nation are dealing with unhealthy sensual life. Many laboratories of counterfeiters are exposed to the open air and use unsterile water that would not be safe for drinking. These results are not surprising, when considering the strict regulations and inspections that legitimate pharmaceutical producers must pass, compared with the unsterile conditions in which counterfeiters may work. Unsuspecting patients often seek alternative treatments of ED due to embarrassment and lower cost, but also because of the perception that “all natural” products are somehow safer than synthetic medications. Recently, in January of 2016, the FDA announced warnings against 40 products marketed as dietary supplements that contained undeclared PDE-5i (33) (Table 3). There is also an indirect risk of missing potential medical conditions in patients that bypass the healthcare system to purchase illicit PDE-5i. The ease and convenience of purchasing counterfeit PDE-5i products via the Internet have contributed to the growth of the illicit market. As stated, counterfeit PDE-5i rarely are packaged with the appropriate warning labels. The effects of widely variable amounts of active ingredient range from low efficacy at a minimum to severe side effects and negative drug interactions at the worst. Quantities of active ingredients are also highly variable, as seen in Table 2. Furthermore according to Fox News report published in November 2007 popping herbal sex pills linked to increased risk of stroke, headaches and vision problems. The types of chemicals found in these medications are making it harder for regulatory authorities to track them down. These Erectile Dysfunction (ED) pills may contain Sildenafil, the active ingredient of Viagra in much higher quantity then legally prescribed by a licensed physician or they may contain unknown quantities of Thiosildenafil, the active ingredient in Cialis. This product as per FDA website has the undeclared ingredient “Sildenafil” and FDA has issued warning Patient reported he is also using “Mojo Risen” which has been shown to contain Noracetildenafil as confirmed by FDA laboratory analysis.While the market for counterfeit pro-erectile medications is partially driven by the cost of prescription drugs, this reality could soon change.In recent years the Food Drug Administration FDA has noted an emerging trend where dietary supplements used for sexual enhancements have untested pharmaceutically active ingredients leading to harmful consequences .Physician should have low threshold in prescribing for erectile dysfunction medication and to carefully monitor patients who are at risk of developing ED in the future to encourage more open conversation about this topic and eliminate the stigma of ED.Furthermore, the manufacturing conditions of counterfeiters cannot match the sterile processing conditions of legitimate pharmaceuticals.Inadequate regulatory measures, weak quality control system and uncontrolled distribution by various vendors are some of the reasons that has augmented herbal supplements market .This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Many factors are contributing to the rapid growth of the illicit market, such as the low risk of prosecution, potentially high financial reward, and ease of distribution via Internet pharmacies.When shopping for male enhancement products, read the label carefully. Surgery is risky and may not work In an analysis of 24,708 patients receiving a PDE-5i, 70% had an underlying medical diagnosis, with 50% of these patients having vasculogenic disease. The Second Princeton Consensus on sexual dysfunction and cardiac risk stated that all men with ED, even in the absence of manifesting cardiac symptoms should be regarded as having potential risks for cardiovascular disease (24). Before PDE-5i are prescribed, patients must be evaluated for potential drug interactions and warned of the absolute contra-indications. This strategy could help ease patient concerns and re-invigorate the PDE-5i market. How Do I Make use of Proflexia RX? A penis is considered small only if it measures less than 3 inches (about 7.5 centimeters) when erect. If your penis is about 5 inches (13 cm) or longer when erect, it's of typical size. The length of a non-erect penis doesn't consistently predict length when the penis is erect. Internet pharmacies have made it easier for PDE-5i users to bypass the healthcare system, as 16.5% of PDE-5i users obtained the medicine through the Internet (13). Increasing household income and availability of a sexual partner positively correlate with their legal use (15). Predictive factors for obtaining PDE-5i while avoiding interaction with healthcare professions were embarrassment and the perception that it would be cheaper to get the medicine through alternative means. In two large surveys, 23–32% of PDE-5i users had no prior interactions with healthcare professionals (13,14). The solution to your concerns about penis size may be as easy as talking with your partner or getting in shape. Even if your penis is smaller than average, it may not matter to your partner. But chances are your penis is within the typical size range. Many men believe that increasing the size of their penises will make them a better lover or make them more attractive. The effects of widely variable amounts of active ingredient range from low efficacy at a minimum to severe side effects and negative drug interactions at the worst.Internet pharmacies have made it easier for PDE-5i users to bypass the healthcare system, as 16.5% of PDE-5i users obtained the medicine through the Internet (13).Before PDE-5i are prescribed, patients must be evaluated for potential drug interactions and warned of the absolute contra-indications.After one month of discharge patient’s condition did not returned to baseline.Recently, in January of 2016, the FDA announced warnings against 40 products marketed as dietary supplements that contained undeclared PDE-5i (33) (Table 3).Many of these side effects occur because there is cross-reaction with other phosphodiesterase types located throughout the body (18,22).There are several frauds and also frauds around, and its vital to be wise when shopping for supplements.This product is structurally similar to Sildenafil the active ingredient in Viagra. This secure and effective supplement has no adverse effects and has been medically confirmed to be reliable. There are also lots of negative effects connected with using this supplement, consisting of anxiousness, sleep loss, as well as exhaustion. There are several frauds and also frauds around, and its vital to be wise when shopping for supplements. In 2009, United Kingdom authorities seized 2,383 samples of counterfeit Viagra and forwarded them to Pfizer laboratories for analysis. The most detrimental problem with counterfeit PDE-5i is that the content is unregulated. Thus, all men with vasculogenic ED should undergo cardiac risk stratification and risk factor management (25). Currently, evidence suggests that ED is not only correlated with cardiovascular disease due to shared medical comorbidities, but is, in fact, an independent risk factor for cardiovascular disease. Proflexia RX Male Enhancement is among these supplements. Yet structure muscle is a procedure that takes some time and effort – which is why lots of turn to muscle-building supplements. Looking for a Male Enhancement supplement that is risk-free and efficient? The use of dietary supplements for treatment of ED should be screened for and given due precautions. Most advertised penis-enlargement methods don't work. So manufacturers don't have to prove how safe a product is or that it works. Marketers rely on ads with people who recommend the product. Companies offer many types of nonsurgical penis-enlargement treatments. Advertisers would have you believe that your partner cares deeply about penis size. Similarly, the FDA has launched significant public education campaigns through magazine public service announcements, education leaflets, news articles, a consumer website (/counterfeit), and a pharmacist education program (36). Even though 57 of 58 products were labeled as “all natural” and no sample claimed to include synthetic substances, 81% contained PDE-5i. In a well-known example, 150 non-diabetic patients were hospitalized with hypoglycemia in Singapore. Globally, antibiotics comprise the largest class of counterfeit medications, but in Europe, PDE-5i are the most commonly counterfeited medicines (7). However, even in these well-regulated countries, the market for counterfeit PDE-5i has grown. Regardless, it is clear that counterfeit medications have reached an industrial level scale. For the purposes of this paper, the term “counterfeit” will be used to encompass all forms of SSFFC medications. Currently, the WHO is using the term “Substandard, Spurious, Falsely labeled, Falsified, and Counterfeit (SSFFC)” for medical products until a new definition is agreed upon (1). Microbial growth analysis of phosphodiesterase-5 inhibitors (PDE-5i) products (29). Contamination with either adulterants or bacteria poses risks to consumers of counterfeit PDE-5i. PDE-5i products purchased from Internet pharmacies rarely contain the stated amount of active ingredient (17). Furthermore, 11.5% of patients being evaluated for a PDE-5i prescription had a new underlying disease detected (26). The counterfeit drug market is a nebulous and constantly evolving entity that has become increasingly difficult to define and quantify. Mayo Clinic does not endorse companies or products. If you are a Mayo Clinic patient, we will only use your protected health information as outlined in our Notice of Privacy Practices. There aren't enough studies of penis-enlargement surgery to give an accurate picture of risks and benefits. Dietary supplements don't need approval by the U.S. In one study, the ingredients of 58 products available for the treatment of ED without a prescription were analyzed.Contamination with either adulterants or bacteria poses risks to consumers of counterfeit PDE-5i.You can drink the male enhancement liquid straight from the bottle, but some men prefer mixing the liquid supplement with water or another drink.The solution to your concerns about penis size may be as easy as talking with your partner or getting in shape.During initial assessment, patient reported he has been abusing over the counter erectile dysfunction (ED) pills since last ten (10) years which he purchased over the internet and from the local grocery stores, with the majority being labeled made in China.Some shoppers want a male enhancement supplement that increases stamina, but some men want a product that only contains natural ingredients. Examples of commonly prescribed medications that have interactions with PDE-5i are included in Table 1. Many of these side effects occur because there is cross-reaction with other phosphodiesterase types located throughout the body (18,22). Other side effects include headache, dyspepsia, flushing, myalgia/back pain, visual disturbances, and nasal congestion. As PDE-5i are active in the vasodilation pathway, there is a risk of profound hypotension and syncope with concurrent use of nitrates and alpha-blockers. There are numerous known side effects of PDE-5i, some of which may be life threatening. He was found unresponsive in his apartment by his home health aide; he had saliva drooling from the mouth, and was unresponsive to questioning from the admitting physician. Two weeks after discharge the patient was brought back to the Emergency Department at metropolitan hospital by friend. This product is structurally similar to Sildenafil the active ingredient in Viagra. This product as per FDA website has the undeclared ingredient “Sildenafil” and FDA has issued warning Patient reported he is also using “Mojo Risen” which has been shown to contain Noracetildenafil as confirmed by FDA laboratory analysis. Furthermore, as mentioned earlier, embarrassment with potency issues leads patients to avoid physician visits. Many factors contribute to the disproportionately large market of counterfeit PDE-5i. In one study attempting to estimate illicit sildenafil use, concentrations of sildenafil and sildenafil metabolites were measured in sewage treatment centers in the Netherlands. Two separate analyses in Europe estimated that 0.6 to 2.5 million men are being exposed to illicit sildenafil compared to approximately 2.5 million users of legal sildenafil (8). These patients with higher socioeconomic statuses having the resources to pay for pharmaceuticals out-of-pocket, combined with the stigma of ED, creates an environment ripe for an illicit market. Between 2004 and 2008, 35.8 million counterfeit sildenafil tablets were seized in Europe, which is 7 times greater than the amount of all other counterfeited Pfizer products combined. Despite these potential dangers, the market for counterfeit products has grown astronomically. The availability of these products through the internet and over the counter in local grocery stores places has a huge clinical challenge to health care. Those products packaging did not list quantity, ingredients, warning sign or harmful side effects of the products. Consumer request has created a huge demand for these products and has led to sales in the hundreds of million to billions of dollars in the US and world-wide 1,3 It is difficult to analyze the herbal products that cause adverse events due to insufficient information, lack of expertise. The liquid products have the same benefits as the tablets and capsules. Nutritional supplements come in several flavors, including a traditional flavor and a citrus flavor. Talking to your doctor before taking any type of sexual enhancement supplement can help you to reduce the risk of any problems. Many men report improvements in their sex lives from the use of sexual enhancement supplements. Because sexual enhancement tablets can have a variety of uses, the ingredients they're made from can vary greatly from product to product. Most products on the market are formulated for the sexual health needs of men and different products are designed to offer different types of benefits. These products are accessible for purchase from local food, drug stores and the internet. You can drink the male enhancement liquid straight from the bottle, but some men prefer mixing the liquid supplement with water or another drink. Liquid supplements contain the same ingredients found in the tablets. You should also look at what the product does because not all supplements promise the same thing. Counterfeiters are taking advantage of this growing market by developing illicit and counterfeit PDE-5i products. Establishment of National and International Databases to better inform the public of the use and consequences of misuse of ED medications and supplements through clear and concise listing of ingredients on product labels. Regulatory agencies emphasizing the impact of the usage of these supplements on the health of general public and striving to impose strict regulations on these products. Patient was encouraged do not use over the counter sexual enhancement products; he was referred to primary care provider regarding consultation for erectile dysfunction. Those who do not like the idea of taking a tablet every day can take liquid supplements. You might find that the product contains the same ingredients as those found in a multivitamin. Using the supplement as directed can also help to ensure best results. Therefore, these patients may turn to using products they deem natural or without side effects and thus believe these products are safer to use. These sexual enhancement products are being sold as safe and natural with false hopes to resolve erectile dysfunction. Some shoppers want a male enhancement supplement that increases stamina, but some men want a product that only contains natural ingredients. Choosing sexual enhancement tablets is a rough task because there are so many different types of products sold under this name. Table 1. Common medications and dietary supplements with interactions with phosphodiesterase-5 inhibitors (PDE-5i). Nevertheless, the use of herbal medicines continues to expand rapidly across world and many people perceive usage of herbal medication as a safe and reliable way to improve health outcome. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The proportion of falsified drugs ranges from 1% in industrialized countries that have a well-regulated and controlled drug market to as high as 60% in some developing countries (6). It is largest in poor and developing countries, with the size of the market being inversely proportional to the amount of regulation. In 2006, the WHO estimated that 10% of drugs worldwide were counterfeit, with the figure at 25% in developing countries, and as high as 50% in certain African and Asian countries (3). Then, all sanctioned medications are manufactured under heavily monitored conditions. PDE-5i have been shown to be safe medications and may ultimately be available over the counter. These dynamics are already evident with many pharmacies advertising for generic sildenafil (20 mg), used for pulmonary hypertension, at a significantly lower cost. This in turn could lead to a decreased demand for cheaper alternative counterfeit options. A simple Internet search for “internet drug store” revealed 6.4 million hits and 7,000 Internet pharmacies. Consumers of illicit PDE-5i often do not realize they are using counterfeit products and placing themselves at an unnecessary health risk. The Public should be educated at local, state and national levels to avoid miss use of sexual enhancement products purchased through the internet or over-the-counter. In recent years the Food Drug Administration FDA has noted an emerging trend where dietary supplements used for sexual enhancements have untested pharmaceutically active ingredients leading to harmful consequences . These products are marketed as supplements and are not currently under the regulations of the Food and Drug Administration (FDA) and are thus released to the general public containing unknown amounts of medications or drugs that are normally available by prescription only in the USA . Many manufacturers market the products as dietary supplements because the products contain natural ingredients, including vitamins and minerals. In one study, the ingredients of 58 products available for the treatment of ED without a prescription were analyzed. As a result, many so-called “natural” supplements, in fact, contain active ingredients of prescription strength drugs that could be potentially harmful. Unlike pharmaceuticals requiring prescriptions, there is little Food and Drug Administration (FDA) regulation of health supplements. While the market for counterfeit pro-erectile medications is partially driven by the cost of prescription drugs, this reality could soon change. With such significant profits to be made at a relatively low risk, there is a tremendous incentive for counterfeiters to tap into the growing market for PDE-5i. Besides the high profit margins, the underlying characteristics of consumers of PDE-5i make it a prime target for counterfeiters. Meanwhile, while the punishment for buying 1 kilo of cocaine would be a minimum of 5 years to a maximum of 40 years in jail, the punishment for buying 1 kilo of sildenafil is typically 3 years (11). With the low cost of base materials and the high cost of pills, the profit margin for creating sildenafil is approximately 2,000 times that of cocaine. The total sewage load was back calculated to estimate total sildenafil consumption, and it was found that greater than 60% of identified sildenafil was not accounted for by legal prescriptions (9). In fact, for PDE-5i, the illegal market in industrialized countries approaches the size of that in developing countries. During initial assessment, patient reported he has been abusing over the counter erectile dysfunction (ED) pills since last ten (10) years which he purchased over the internet and from the local grocery stores, with the majority being labeled made in China. Later patient called his friend and request to take him to nearby healthcare facility Patient reported right hemiparesis, unstable gait and imbalance. The pills marketed as safe herbal alternatives to Viagra and other prescription medication for erectile dysfunction exhibits a hidden danger and adverse effects especially among people with pre-existing heart conditions. Understanding your partner's needs and desires is more likely to improve your sexual relationship than changing the size of your penis. Implement tougher guidelines and monitoring of products sold by manufacturers and to implement regulatory monitoring on the companies involved in manufacturing of over the counter products. Since these supplements are not regulated by the FDA consumers and vendors considered it safe until proven otherwise. Men who wish they had more stamina in the bedroom sometimes reach for male enhancement products. Sexual enhancement tablets are not FDA-approved over-the-counter medications, so they typically contain natural ingredients. There are also products that are formulated to address concerns with penis size.