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Effect of once-daily tadalafil on confidence and perceived difficulty in performing sexual intercourse in men who were incomplete responders to as-needed PDE5 inhibitor treatment

Performance Anxiety and How To Overcome It

Dr. Aysha Butt is the Medical Director of FROM MARS, and is a GP Partner at Woodcote NHS Medical Practice.

Sex is fun, right? Except sometimes it can be stressful. You want things to flow in bed, but this may not always be the case. Overthinking is something that we’re all guilty of, even the little things, so when you start to worry about your performance and question yourself there may be no performance at all.

Whether you think you’re not big enough, have doubts as to whether you’re able to last long enough or if you think your partner isn’t enjoying it, sexual performance anxiety is something that can affect most males.

It’s natural to have doubts, but you shouldn’t let it define you.

Performance anxiety and erectile dysfunction

Feeling stressed and anxious about sex can cause problems for both men and women. For guys one of the most likely results of sexual performance anxiety is erectile dysfunction (ED), which means that you can struggle to either get or maintain an erection.

You may want to have sex with your partner, but if your head isn’t in the right place you can have problems getting and staying hard. If you’re too stressed your body just won’t react the way you want it to. This can be embarrassing and it can leave you feeling powerless.

Causes of performance anxiety

Having sex isn’t just a purely physical act and sometimes your emotions can get in the way of having a good time. There are many worries that may run through your head if you are experiencing performance anxiety, including:

  • Thinking that your penis isn’t big enough for your partner
  • Worrying that you won’t be able to last as long as they want
  • Fear that you don’t like to do the kind of things they do, or that you’re not good enough at them
  • Poor body image, such as worrying that you’re overweight, not muscular enough, or generally that you don’t like how you look naked
  • Fear that you’re not masculine or dominant enough for your partner
  • More general worries and stress from your life, be it work, finances, or problems in your relationship

Do I have erectile dysfunction or performance anxiety?

The two are related. Sexual performance anxiety can cause erectile dysfunction if the anxiety is strong enough, but performance anxiety isn’t the only cause of ED. You might feel anxious about sex, but there could be another reason that’s causing it.

There are lots of possible causes of erectile dysfunction; some physical, some mental and others related to lifestyle choices. Some causes are easily addressed, but others can be more serious.

You owe it to yourself to work out what’s causing any problems and what the solutions are.

How to overcome performance anxiety?

You’re probably asking yourself how to fix performance anxiety. A lot of the time it’s about getting your head right. Try some of the following:

Talk about it

As difficult as this might be, it can really help. Tell your partner how you’re feeling and what’s going on in your head. It doesn’t have to be embarrassing or emasculating. You don’t have to tell them you’re worried you’re not good enough, but frame it instead as being concerned about giving them as much pleasure as you can.

You might find your partner is just as anxious as you are and sharing your feelings may help you both relax and have better sex together.

Get your own expectations straight

You want to give your partner the best sex you can, we get it, but if you’ve had sex before and they’re back for more, remember, it means they like you and they want to do it again, so try not to worry.

If it’s going to be the first time with someone new, then remember that sex is like a conversation. It’s not just down to you, it takes two to have a good conversation and the better you get to know the person the better it usually goes. It’s the same with sex. The first time might be a little awkward, but that’s natural. It’ll get better with time.

Become a master of foreplay

Focus on your partner and think about how you can give them as much pleasure as possible. That means getting good with your hands and mouth. It can really take the pressure off.

If you get them screaming your name before you get down to sex they’ll be a lot more relaxed about what happens after. If your partner is female the reality is that a lot of women don’t orgasm from penetrative sex anyway and if you make her climax before you’ve even entered her she’ll likely be happy whatever else happens.

Exercise to reduce stress and control your thinking

Meditation and mindfulness techniques can help to get control of your negative thoughts, so you can get rid of any anxiety before it gets a hold of you. Even small things like taking a hot shower before sex can de-stress and relax you.

Consider therapy

If none of the above are helpful you can talk to your doctor and ask to be referred to a therapist who can help you learn to better manage your anxiety. You can also try finding a private therapist.

Try erectile dysfunction treatments

Sildenafil (the active ingredient in Viagra) is commonly used to treat erectile dysfunction and is generally safe to use in moderation. It works by relaxing the walls of blood vessels inside the muscles of certain areas of the body and has helped many men get their confidence back.

If you don’t have underlying medical problems you shouldn’t see Viagra as a permanent solution to erectile dysfunction caused by performance anxiety. But it certainly can help as a temporary solution.

If you’re with a new partner, or it’s been a while, or you just feel you need to get your mojo back, Viagra can help to guarantee an erection and can take your mind off your anxiety. You need to make sure you don’t use Viagra as a crutch though. You still need to address the causes of your performance anxiety.

Performance anxiety might feel overwhelming at times, but it’s a common problem and one that you can work to resolve. You can soon get back to your old self.

Effect of once-daily tadalafil on confidence and perceived difficulty in performing sexual intercourse in men who were incomplete responders to as-needed PDE5 inhibitor treatment

Introduction: For men with erectile dysfunction (ED), the expectation of difficulty and level of confidence in achieving and maintaining an erection have an impact on sexual performance.

Objective and methods: This 12-week, double-blind study investigated once-daily tadalafil (2.5 mg titrated to 5 mg or 5 mg) (n = 176) or placebo (n = 79) on confidence and perceived difficulty in performing sexual intercourse in men with ED who were incomplete responders to as-needed phosphodiesterase-5 inhibitor therapy. The Confidence in Performing Sexual Intercourse Questionnaire (CPSIQ) and Difficulty in Performing Sexual Intercourse Questionnaire (DPSIQ) were administered at baseline and 12 weeks.

Conclusion: Once-daily tadalafil vs. placebo improves confidence and decreases difficulty in performing sexual intercourse for men with ED who were incomplete responders to as-needed PDE5 inhibitor therapy.

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Can stress and anxiety cause ED?

Erectile dysfunction (ED) affects nearly 20% of men in the U.S. , but the link between stress, anxiety, and sexual health isn’t often addressed. Psychological inputs allow the body to achieve erections at a desired time—mental distractions affect that ability.

The sexual response cycle has four main phases: desire, arousal, orgasm, and relaxation. Erectile dysfunction specifically relates to arousal. Feeling anxious or stressed can make it hard to feel or sustain sexual pleasure. “ There are a lot of misconceptions that erectile dysfunction has something to do with desire, ejaculation, or even climax,” says Ryan Berglund, MD, a urologist at the Glickman Urological & Kidney Institute at Cleveland Clinic. “It is purely the inability to obtain and maintain an erection sufficient for intercourse.”

Can stress or anxiety cause erectile dysfunction?

“Anything that can lead to anxiety can inhibit the ability to get an erection,” says Dr. Berglund. That includes daily stressors, mental health conditions, and performance anxiety.

Psychogenic erectile dysfunction

When outside stressors and other psychological factors are behind ED, it’s categorized as psychogenic erectile dysfunction. It generally happens in two ways. Anxiety causes a mental distraction, making it challenging to focus on sex. Or, stress can cause an increase in sympathetic nerve activity (think: the fight-or-flight response).

“Interestingly, the part of the autonomic nervous system that stimulates an erection is the parasympathetic nervous system, which is what is at work when you’re resting or sleeping,” explains Dr. Berglund. Your body’s stress response counteracts the parasympathetic system, which works when you’re at rest. Meaning, it’s nearly impossible to stay aroused when you’re seized with fear and panic.

Depression and anxiety disorders

There is also an association between depression, anxiety, and erectile dysfunction—likely due to general life dissatisfaction, reduction in sexual desire, or medication side effects, notes Yooni Yi, MD, assistant professor, Department of Urology at Michigan Medicine.

Performance anxiety

Performance anxiety occurs when your attention is focused on negative thoughts or worries about pleasing your partner—rather than the erotic stimulation that causes arousal. It’s a specific type of sexual stress that affects 14% to 25% of men, according to Dr. Yi. Over time, performance anxiety can diminish self-esteem, sexual confidence, and partner communication—and even lead to relationship conflict or resentment.

How do you treat erectile dysfunction from stress or anxiety?

Alleviating psychogenic erectile dysfunction or performance anxiety is a process, not a quick-fix. “It is important for the patient to accept this at the start of treatment,” Dr. Yi says. If possible, it is also beneficial for your partner to be involved throughout the process.

1. Determine the cause.

Often, the cause of erectile dysfunction is multifactorial. In other words, there can often be multiple causes, including changes in blood flow to the penis, altered nerve function, hormones, medications, prior surgery, and psychological factors, says Dr. Yi.

Situational erectile dysfunction (like being able to get an erection via masturbation, but not with a partner) is a key symptom of psychogenic erectile dysfunction. If the cause is medical in nature, your physician will get a detailed history and perform a physical, possibly including blood work. Morning erections noted at the time of waking up, while one is still having issues with ED with a partner, also point toward psychogenic erectile dysfunction.

2. Reduce triggers.

If you recognize a particular stressor is contributing to performance anxiety or erectile dysfunction, try to avoid those situations. Discussions with your partner—including expectations of erection duration, nervousness about the refractory period, or body insecurities—may help alleviate some of these triggers of stress and ED.

3. Consider medication.

PDE5 inhibitors (like Viagra , Levitra , and Cialis ) can enhance your sexual response, even if you’re experiencing stress or performance anxiety—but they may not get to the root of the issue. “A lot of times when we treat erectile dysfunction, we actually just empirically put the patient on PDE5 inhibitors without necessarily addressing the primary problem,” says Dr. Berglund. “These medications help the ability to obtain and maintain an erection, but it doesn’t address other underlying problems like relationship issues or diminished libido or desire.”

If you’re in a prolonged state of anxiety, a better solution may be to address the underlying psychological problem, with a visit to a mental health professional. In some cases, anxiety-induced ED is treatable with medication. However, certain medications used to treat depression, anxiety, or high blood pressure can also make it difficult to get an erection. Talk to your doctor about your concerns to find the right treatment plan.

4. Consult a therapist.

If these steps haven’t alleviated the issue, your physician may refer you to a mental health professional or sex therapist. “These sessions can work on exploring barriers, communication techniques, anxiety reduction techniques and adjuncts that will help in overcoming the psychological aspects of erectile dysfunction,” says Dr. Yi.

It can take time to completely eliminate anxiety’s effect in the bedroom, but don’t give up. With the right treatment (and a little persistence), your sex life can return to normal.

Performance Anxiety

Anxiety can have a strong impact on how we have sex. For as many as 25% of people, anxiety around sex can get in the way of erections or orgasms.

Luckily, there’s a few different ways you can overcome sexual performance anxiety and get back to enjoying sex.

Contents

What is sexual performance anxiety?

Sexual performance anxiety is when you feel fear or worry about your ability to have sex. These feelings can make it difficult to enjoy sex, and in some cases can make you unable to perform. This can happen before having sex, or during.

‘Performance anxiety’ is when doing something in front of another person or a group of people gives you anxiety (also known as ‘stage fright’) and is related to social anxiety. It can happen when you need to do things that can cause you to feel anxious such as taking an exam, visiting the doctor, having a job interview, or speaking in public.

Whether sexual or non-sexual, it can be completely normal to experience a small amount of performance anxiety, including performing in bed. However, performance anxiety can affect people differently, and for some, it can cause panic attacks or affect their day-to-day life.

A study published in 2019 showed that sexual performance anxiety affects between 9% to 25% of men and 6% to 25% of women.

Does performance anxiety only happen with a new partner?

Being in a new relationship can be exciting, but it can also be a reason for getting sexual performance anxiety. You might be worried about pleasing your new partner and even worried the relationship will end if you can’t.

Lots of people in new relationships feel this way so it’s completely normal. Remember that your new partner probably feels the same way. After you’ve been partners for long enough to feel more secure, and you’ve had sex more often, the sexual anxiety should get better. There are also some tips listed below that could help you through any early rough patches around sex with a new partner.

While anxiety with a new sexual partner is a common cause for performance anxiety, it’s not the only reason for it.

Some other common triggers of performance anxiety can include:

  • Not feeling great about the way your genitals look or feel, or poor body image in general
  • Work-related stress
  • Problems in your personal relationships
  • Financial stress
  • Problems with your love life
  • Worrying about coming too early (premature ejaculation), taking too long to come (delayed ejaculation), not being able to get or stay hard (erectile dysfunction), or getting pain during sex

Check out our research on what fears people have around sex:

View Erectile Dysfunction Treatments
View Erectile Dysfunction Treatments

Can performance anxiety make you lose your erection?

Yes. Many men find they can’t get or keep erections because of anxieties around sex, known as psychological erectile dysfunction. This is actually the leading cause of erectile dysfunction in younger men and doesn’t mean there’s necessarily something physically wrong with you.

Even if your erectile dysfunction is psychology and not physical, you might still be able to get treatment. Erectile dysfunction medication is effective and safe when approved by a doctor and it can help even with anxiety-related erectile dysfunction.

If your erectile dysfunction is new or sudden, you should speak to a doctor to rule out physical causes for it, regardless of whether it is mainly psychological or not.

Can performance anxiety make it hard to orgasm?

Yes. Some people find they can get hard enough to have sex, but can’t reach orgasm because of the pressure they feel during sex. Not being able to orgasm (anorgasmia) is a common side effect of performance anxiety.

If you have an anxiety disorder and you’re using medication to treat it, you may be getting anorgasmia as a side effect from your treatment.

Can anxiety make you orgasm too quickly?

Yes. While some men find the pressure to perform in the bedroom stops them from orgasming, others find the increased anxiety causes them to orgasm faster than they want. If this is the case for you, as well as getting treatment for your anxiety, you could try premature ejaculation treatment.

How can you get over performance anxiety?

Like other forms of anxiety, you can get counselling or therapy to help manage it. You can get cognitive behavioural therapy (CBT), or other types of therapy on the NHS.

As well as counselling or therapy, there are some other lifestyle changes or techniques you could try to improve your performance anxiety, including:

  • Use meditation and mindfulness exercises
  • Get rid of stress factors in your work and life
  • Change your negative thought patterns with cognitive behavioural therapy
  • Avoid rushing sex
  • Discuss your worries and anxiety concerns with your partner
  • Try sex therapy to work through performance and intimacy issues
  • Learn more about sex and sexual behaviours
  • Go to couples counselling to help with relationship problems
  • Try talking therapy to manage stress and other life challenges

If you need help or someone to talk to, Relate are an organisation the NHS recommend to help you handle sex and relationship issues.

How to get and keep erections with performance anxiety:

You can treat erectile dysfunction caused by performance anxiety the same way as other types of erectile dysfunction. Counselling and lifestyle changes can help, but you also get medications to help you get and keep erections, even with sexual performance anxiety, including:

Other medications for performance anxiety:

As well as helping you get and keep erections, there are other medications that can help you manage sexual performance anxiety, including: