Erectile dysfunction (ED) is an increasing disorder , affects 25 to 35 million men over 18 years in Europe. Pharmaceuticals used to reduce this disorder act as phosphodiesterase-5 (PDE-5) inhibitors, a family of enzymes typically active in cyclic guanosine monophosphate (cGMP) degradation. The inhibition of PDE-5 results in the intracellular accumulation of cGMP, which plays a central role in signal transduction and regulates several physiological responses.
Emerging pollutants (EPs) are synthetic or naturally occurring compounds not commonly examined in the environment 
. Still, they can enter ecosystems and cause recognised or supposed adverse effects on ecology and human health 
. Moreover, they undergo chemical/biological transformations, forming by-products sometimes more toxic than the parent molecules. The final issue is the accumulation of original and transformed substances in water bodies 
. In particular, Zuccato et al. 
evidenced the presence in ground and surface waters of drugs and pharmaceuticals having polar structures, probably coming from WWTP effluents.
When absorbed by the body, a pharmaceutical substance enters the circulation and distributes to reach the target site to perform its function 
. When the metabolism process is activated, some molecules reach the target site and others transform into inactive metabolites, which are substances no longer producing effects into the body. Many medicines, however, are excreted without being metabolised or at least without being completely inactivated 
. These, together with sewage, reach the WWTP, where organic loads degrade and water is purified. Unfortunately, these structures are often not designed to degrade active substances of pharmaceutical origin, which, therefore, once again manage to resist, unharmed, and maintain their effectiveness. As a result, the purified water (still rich in active ingredients) flows into the receiving channels, carrying a load of pollutants to rivers and lakes. Thus, tons of active substances such as antibiotics, anti-neoplastic, estrogens and others are poured into surface waters 
. Once in the environment, the drug eventually degrades or can persist very long, resulting in noticeable build-ups 
. In the sediments of some Italian rivers such as the Po, Lambro and Adda rivers, as well as in the aqueducts of the towns of Varese and Lodi, traces of various drugs were present in different amounts, including antibiotics (lincomycin and erythromycin), anticancer (cyclophosphamide), anti-inflammatory (ibuprofen), diuretics (furosemide) and antihypertensive (atenolol) drugs 
. The existence of these compounds in environmental systems is of concern since they constitute a complex assortment, which could induce the occurrence of undesirable synergistic effects and could be responsible for many health adverse effects such as allergies, development of antibiotic-resistance phenomena, disorders of the endocrine system, cytolytic or cytostatic effects and others 
2. Source of PDE-5 Inhibitors in the Environment
According to the “anatomical therapeutic and chemical
” (ATC) classification system, PDE-5 inhibitors are available in the class ATC code G04BE. The four most significant inhibitors used are sildenafil (Viagra®
), tadalafil (Cialis®
), vardenafil (Levitra®
) and avanafil (Spedra®
), all approved by Food and Drug Administration (FDA). In addition, there are other pharmaceuticals that are non-FDA approved and commercially available in some countries, such as udenafil (Zydena®
) in South Korea and Malaysia, mirodenafil (Mvix®
) in South Korea and lodenafil carbonate (Helleva®
) in Brazil 
S) was discovered in 1989 by the Pfizer Cardiovascular Research and Development Group (Sandwich, Kent, UK) during research focused on identifying PDE-5 inhibitors to treat angina pectoris due to the abundant presence of the PDE-5 enzymes in platelets and vascular smooth muscle cells. It showed low effectiveness on angina pectoris tests and penile erection as the primary collateral effect 
. The FDA, in 1998, approved sildenafil for erectile dysfunction treatments and then in 2005, the European Medicine Agency (EMA) approved it for class II and class III pulmonary hypertension treatments. Vardenafil (C23
S) and tadalafil (C22
) were introduced clinically in 2003, while avanafil (C23
) in 2013. Although the structural differences between these compounds are minor, they have different pharmacokinetic properties (absorption, distribution, metabolism and excretion). In addition, they can exert their activity also on other PDE-types, as reported in Table 1 
Pharmacokinetic parameters of PDE-5 inhibitors (re-edited from 
||1 h (median)
0.5–2 h (range)
|1 h (median)
0.5–2 h (range)
|2 h (median)
0.5–6 h (range)
|0.5–0.75 h (range)
Minor: CYP3A5, CYP2C
|Active metabolite(% effect)
|Ingestion with high-fat meals
||↓ Cmax 29%
↑ Tmax by 1 h
|↓ Cmax 18–50%
||↓ Cmax 24–39%
↑ Tmax by 1.12–1.25 h
|Additional PDE inhibition
All four PDE-5 inhibitors are rapidly absorbed from the gastrointestinal tract and show broadly similar Tmax
, except for tadalafil which has the longest Tmax. Peak plasma concentration (Cmax
) of sildenafil is reached in less than 1 h 
. Vardenafil and avanafil have similar pharmacokinetics to sildenafil, with Tmax approximately 1 h 
and 30–45 min 
. Tadalafil reaches its maximum concentration in plasma after about 2 h 
Sildenafil, vardenafil and avanafil have a terminal half-life (T1/2) of between 4 and 5 h, and tadalafil has a half-life of 17.5 h.
Huang et al. 
reported that each PDE-5 inhibitor undergoes metabolism predominantly through the hepatic isoenzyme cytochrome P450 (CYP) 3A4 pathway. Minor pathways include CYP2C9 for sildenafil, CYP3A5 and CYP2C for vardenafil and CYP2C for avanafil. Of these four pharmaceuticals, only tadalafil produces human metabolites that are not pharmacologically active. Sildenafil predominantly metabolises into an N-desmethyl metabolite that contributes to approximately 20% of the parent molecule total pharmacological activity 
. Vardenafil and avanafil produce active metabolites that contribute 7% 
and 4% 
of the real pharmacological action. All the PDE-5 inhibitors mainly excrete as metabolic by-products in the faeces and to a reduced amount in the urine.
Thanks to their different features, some PDE-5 inhibitors can be used in many clinical treatments and not only for erectile dysfunction treatments. For example, the national medicines agencies approved tadalafil for: (i) the treatment of lower urinary tract symptoms (LUTS); (ii) secondary to benign prostatic hyperplasia (BPH); and (iii) for the treatment of pulmonary arterial hypertension (PAH), a condition of increased blood pressure within the arteries of the lungs 
Sildenafil is approved for PAH treatment because it inhibits the PDE-5 in the pulmonary blood vessels and promotes the vasodilator action of nitric oxide by maintaining high cGMP levels 
In addition, researchers performing mice models with Alzheimer’s disease proved that PDE-5 inhibitors can effectively promote the cGMP-mediated processes involved in consolidating information in memory and countering the neurodegenerative mechanisms typical of Alzheimer’s disease 
Schnetzler et al. 
estimated that about 6 million men in Europe could avoid the healthcare system to get PDE-5 medicines themselves. Market globalisation and the Internet are offering new scenarios and creating unknown risks for public health due to the growing attitude to buy drugs from the illegal market and online shops, exposing in this way more and more persons to the hazards due to the intake of illicit and counterfeit drugs 
. Authorities developed specific legislative rules, particularly the European Directive 2011/62/UE, to avoid the trade of falsified medicinal products through the permitted supply chain. This Directive also normalises the Internet market of legal medicines by specifying that legal online pharmacies are obligated to exhibit a “common logo” on each page of the website dedicated to drugs sale 
. An exciting and recent study 
listed 80 new sexual performance enhancers detected illegally in the market that mimics the approved PDE-5 inhibitors.
3. Content of PDE-5 Inhibitors in WWTPs and STPs
Together with many other pharmaceutical products, these substances, once eliminated in faeces and urine, are transported through sewers to municipal wastewater treatment plants. Here, the parent substances and their metabolites are treated in biological reactors, which can only partially degrade them while triggering other transformation processes. They also often undergo accumulation processes before being discharged into the receiving water bodies. For this reason, investigations about the residues of these pharmaceuticals in the environment are essential to proceed with their removal. The first approach consists of determining the PDE-5 inhibitors’ content in untreated wastewater samples taken at the entry into WWTPs. Despite the low or very low solubility in water and the positive values of the partition coefficients (Log P), these products can arrive at municipal wastewater treatment plants adsorbed on the solid organic materials or dispersed in the liquid mass. Their lipophilicity favours their transport.
Research performed in eight WWTPs serving the catchment inside the towns of Bristol, Brussels, Castellón, Copenhagen, Milan, Oslo, Utrecht and Zurich 
showed the presence of sildenafil and its two human urinary metabolites, desmethyl- and desethyl-sildenafil with amounts up to 60 ng L−1
. They did not detect tadalafil and vardenafil in appreciable concentrations. The authors transformed the concentrations found in the collected samples to normalised loads and estimated the possible intake of sildenafil as amounts back-calculated from these loads. Moreover, they gathered the national prescription data from five countries in the form of the number of prescribed daily doses and transformed them into predicted loads for assessment. In Utrecht and Brussels, prescription data could only partially clarify the total quantity determined in wastewater.
In contrast, in Bristol, Milan and Oslo, the authors found that drug amounts in wastewater were lower than predicted from the prescription data. These studies illustrate the theoretical capacity of performed investigations to assess the use of imitating fraudulent medication and criminal online sales. Other researchers in Tarragona (Spain) and Germany determined the occurrence of these pharmaceuticals in WWTP influent and effluent water and sewage sludge 
to evaluate the removal efficiency of the treatment systems and the possible influence of STPs on the pollution of the aquatic systems.
Sildenafil was the principal drug in all investigated water and sewage samples at a few ng L−1 and ng g−1 range, respectively. Tadalafil was not identified or below the limit of detection (LOD) in effluent water collected in Spain but was revealed in sewage sludge (12 ng g−1–LOD). Vardenafil was detected only in one sludge sample and between 5 ng g−1 and the LOD value in effluent water. The higher elimination efficiency of the STP in Tarragona (Spain) was 68%, 69% and 80% for sildenafil, tadalafil and vardenafil, respectively.
The monitoring evidenced the maximum concentrations for all drugs during the summer, probably due to the touristic fluxes (Figure 2
, from