Everything You Need to Know About Sexual Performance Anxiety and Erectile Dysfunction

By Natalya Lopushnyan, MD
Medically reviewed
March 30, 2021

Men commonly experience sexual performance anxiety (SPA) and erectile dysfunction (ED). However, due to the highly sensitive nature of these conditions, both are often under-diagnosed, under-treated, and not frequently discussed. 

This article will explain and differentiate SPA and ED, how each affects men’s sexual experience, and ways to treat these sexual conditions.

What Is Sexual Performance Anxiety?

Sexual performance anxiety (SPA) is when you experience stress and worry about your body image as well as about pleasing your partner during intimacy and sexual intercourse. It’s not completely clear whether SPA is solely related to sexual performance or if it is a manifestation of underlying general anxiety that’s worsened by intimacy. 

Either way, SPA is one of the most common sexual complaints, affecting 9-25% of men and up to 16% of women. However, the condition is frequently overlooked and many people don’t get the necessary treatment. One reason for this may be because anxiety about sexual performance is very subjective and varies from person to person. 

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Erections and sexual arousal are complex processes that involve an interplay between emotional and physical factors in men. Changes on the emotional side can lead to the physical issues of ED, and vice versa.

Sexual anxiety can contribute to ED in several ways. Say someone worries they may not be able to satisfy their partner during sex. They may start feeling unworthy and incapable, and these feelings of inadequacy can result in ED. 

Previous experience plays a huge role in SPA as well. Men who had even minor issues with erections or intercourse in the past may ruminate about these past negative experiences, causing them to have negative feelings about intercourse in general. In turn, their excitement about sex decrease as they continue to worry about their abilities. 

Causes of Performance Anxiety

SPA is more frequently seen in individuals with social anxiety and panic disorders, so it may be a part of a broader anxiety disorder. But not everyone with SPA has clinical anxiety.

In many men, prior negative experiences during intercourse cause their current anxieties.

For example, if a man lost his erection or had premature ejaculation in the past, leaving his partner unsatisfied, it could play out in his brain repeatedly, leading to the same problem.

And if a man is not fully emotionally present during intercourse because he’s worrying about other issues, that will likely affect his overall state during sex. 

Causes of Erectile Dysfunction

SPA is a common issue and may be the main reason some men experience erectile dysfunction. However, ED involves a complex interplay among a man’s brain, emotions, vascular system, nerves, muscles, and hormones. Dysfunction in any of those components can lead to ED. 

Some of the more common causes of ED include:

  • Diabetes
  • Heart or vascular disease
  • High blood pressure
  • High cholesterol
  • Clogged blood vessels (atherosclerosis)
  • Metabolic syndrome and obesity
  • Neurologic diseases
  • Smoking or any other tobacco use
  • Alcoholism or other substance abuse
  • History of prostate cancer and treatment for prostate cancer
  • Low testosterone
  • Previous surgeries or injuries to the pelvis
  • Previous back injury or surgery
  • Peyronie’s disease 
  • Certain prescription medications
  • Older age

Symptoms of ED

The symptoms of ED are easy to recognize and include:

  • Difficulty getting an erection
  • Difficulty keeping an erection
  • Difficulty achieving an orgasm
  • Reduced interest and sexual desire

ED and Mental Health

Problems with ED can affect a man’s self-esteem, cause relationship problems, and increase stress. Unfortunately, ED and performance anxiety can be a self-perpetuating cycle that has a significant effect on sexual satisfaction.

If a man experienced sexual issues in the past that made him feel incapable or unworthy, it can affect his future sex experience, occasionally leading to complete impotence.

At the same time, men who felt ashamed during intercourse in the past frequently report having issues with their erections when they are with a partner but have no problems during masturbation. 

Overcoming ED and Performance Anxiety

Having an understanding partner is very important if you have ED or performance anxiety. Additionally, some tips can help decrease performance anxiety and improve your sexual experience.

Do not focus on the past

It is essential to understand that occasional difficulty with erection does not mean that you are unable to have sex. It may mean that at that particular time you were more stressed, and that affected intercourse. When stress is lessened, however, the issue may not exist at all.

It is important to shift the focus to why the erectile dysfunction happened rather than focusing on the negative outcome. Talking to your partner and reducing the pressure on yourself may help prevent future performance anxiety. 

Concentrate on being in the moment

If you are not fully present in the here-and-now, it takes away from the sexual experience for both you and your partner. Trying to be present and fully participate without being distracted often helps couples have an enjoyable time together. Meditation and other relaxation techniques have also been shown to help in this case. 

Lifestyle changes

Men frequently report worsening erectile functions when they are going through a stressful period in their lives. Whether it is related to their job, relationship, or something else, this stress can initiate ED or exacerbate existing ED.

And overall, higher stress levels and generalized anxiety are related to decreased sexual satisfaction in both men and women. Addressing those issues and finding ways to manage stress frequently improves the overall experience of sex.

Smoking, alcohol, or any illicit drug may also worsen erections and overall health. 

ED Treatment Options

If SPA is the cause of ED, various treatments exist, depending on your medical history and the severity of the condition.

Frequently men with sexually related anxiety benefit from behavioral therapy and counseling. If SPA is a recurrent issue with the same partner, couples therapy may be helpful. In other cases, medications such as certain antidepressants, anti-anxiety drugs, and PDE5 inhibitors such as sildenafil (Viagra) and tadalafil (Cialis) can be used. 

Various treatment options also exist for ED that is not caused by performance anxiety.

Lifestyle modifications

Erectile function reflects a man’s general health. The healthier you are, the better your erections will be. Lifestyle changes such as quitting smoking, losing weight, and eating a healthier diet have been shown to improve men’s overall health and quality of erections. 

Oral medications

Oral medications that increase blood flow to the penis by relaxing the vessels that deliver blood successfully improve ED in many men. The most common medications are:

The dosage, duration, and side effects of ED medications vary. Generally, they’re taken 30 minutes to an hour prior to intercourse with a glass of water on an empty stomach, as that improves the medicine’s absorption and effectiveness.

Note that although the medication will augment an erection and improve the quality of a sexual experience, taking the medication alone will not produce an erection. Sexual stimulation or foreplay is needed. 

ED medications work better in people without significant nerve damage. They should not be taken by anyone who takes nitrates (medications commonly prescribed for chest pain) or who has heart disease, heart failure, or very low blood pressure. 

Penile injections and suppositories

Not everyone responds to oral ED medications. For these individuals, penile injections or intraurethral suppositories may help. 

Penile injections contain compounds that allow better blood flow to the penis. Generally, a man will self-inject a small amount of medication into a side of the penis 10-15 minutes before the intercourse. 

Intraurethral suppositories are small pellets inserted into man’s urethra to aid an erection. They contain alprostadil, which improves blood flow to the penis. The alprostadil is absorbed through the urethra and starts working within 10-15 minutes. Side effects include pain with insertion, burning inside the penis, and possibly minor bleeding. 

Vacuum device

A vacuum device (or penis pump) is a hollow tube placed over a man’s penis that sucks out the air inside the tube. This creates a vacuum, which brings more blood to the penile tissue and improves erections. While some men find them helpful, penis pumps can be cumbersome to use. 

Penile implant surgery

For patients with severe ED who do not respond to other treatments, there is an inflatable penile prosthesis (IPP). This hydraulic device is implanted inside the penis and replaces the erectile tissue. It generally has a small pump that is placed inside the scrotum. By squeezing the pump, fluid travels to the IPP cylinders inside the penis and produces an erection. This is a very reliable method to treat ED, however, it involves surgery. 

When to See a Doctor

Occasionally feeling uneasy or anxious about sex or having minor erection issues is not cause for concern. However, if those issues become more frequent and sexual intercourse is no longer enjoyable for you or your partner, you may benefit from talking to a doctor. 

At K Health, we are dedicated to the wellbeing of our patients. Chat with a doctor and get fast, affordable ED treatment from your phone. You can even get your prescription delivered discreetly to your door.

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K Health articles are all written and reviewed by MDs, PhDs, NPs, or PharmDs and are for informational purposes only. This information does not constitute and should not be relied on for professional medical advice. Always talk to your doctor about the risks and benefits of any treatment.

Natalya Lopushnyan, MD

Dr. Natalya Lopushnyan is a board certified Urologist specializing in Men's Health. She earned her degree in Biochemistry from University of Massachusetts Boston, graduating Summa Cum Laude. Her MD is from Yale. She completed Urology Residency at the University of Washington in Seattle.