Sexual Performance

Sexual performance is one of those topics where guys sit on a problem for years before bringing it up, and then when they finally do, it’s at the end of an appointment that was nominally about sleep, mood, or blood pressure. “Oh, one more thing.” The one more thing is almost always the actual thing. The sleep complaint was the warm-up.

This is partly cultural and partly how the system is built. No primary care doctor has fifteen minutes to spend on erections. Urology feels like a big deal to see. Psychiatry doesn’t get raised because most guys don’t think of this as a head problem. So it sits, and while it sits, the original problem (which is usually pretty fixable) gets layered with a performance-anxiety problem that wasn’t there at the start. You can put lipstick on a pig, but it’s still a pig… and the pig in this case is the conversation you’ve been avoiding with somebody who could have started fixing it eighteen months ago.

Roughly half of men over forty have some erectile dysfunction. Premature ejaculation hits something like one in three guys at some point. Those numbers haven’t really moved in decades. You are not in a small or weird group, you’re in the absolute middle of the bell curve, you just don’t talk to your friends about it because nobody else is talking about it either.

And it is not only an older-man problem, which is exactly the part that keeps the youngest guys the quietest. Plenty of men in their teens and twenties deal with this too, and at that age it is almost never the plumbing, it is performance anxiety and stress and too much porn quietly recalibrating what arousal is supposed to feel like and sometimes an SSRI nobody ever connected to the problem. It is also far more common than any twenty-two-year-old lying awake convinced he is the only one would ever guess, and the research actually bears that out, because when one large clinic looked at men coming in for brand-new erectile trouble, a full quarter of them were under forty and nearly half of those young guys had the severe kind rather than the occasional off night. The sad part isn’t the symptom, it is the silence around it, since a young guy will carry this for years assuming it is a life sentence when at that age it is usually one of the more fixable versions of the problem there is, and he stays quiet because he is sure he is broken in a way nobody else his age could possibly be. That is almost always backwards.

The pill doesn’t create desire, it amplifies what’s there, and if the desire isn’t there no PDE5 inhibitor in the world is going to fix that.

Vascular versus psychogenic, the first sort that has to happen

For the broader workup picture (sleep apnea and depression as mimics, specialist routing, hormones), see sexual health. This post is the deep dive on the medications and the procedures.

Before anybody reaches for a prescription pad, the question worth answering is whether the plumbing is the problem or whether the brain is the problem. The rough-and-dirty test most clinicians use is morning erections. If you’re waking up with them, getting them during the night, getting them reliably with masturbation but not with a partner… the hardware works. The wiring works. What’s failing is the part of the system that involves another person being in the room, which is a head problem with a body symptom, not a vascular problem.

If morning erections have disappeared, if firmness has been gradually fading over years, if you can’t get one in any context including the shower at 6 AM, the differential shifts toward vascular. That usually means small-vessel disease, which is the same biology that drives heart attacks and strokes, just showing up earlier in a smaller artery. ED in a fifty-year-old is often the first warning shot from his cardiovascular system, which is why a real workup includes glucose, cholesterol, blood pressure, and sometimes testosterone. The downtown plumbing is an early-warning system… pay attention to it before the same physiology starts knocking on a bigger artery.

For example, let’s say a guy in his late forties comes in convinced he’s depressed because his sex life has cratered. Sleep is fine. Mood is mostly fine when you press on it. Erections have quietly degraded over a year and a half and he’s built a whole story around being broken, ended up sleeping in the guest room “because of snoring.” The workup turns up uncontrolled blood pressure and prediabetes. Tadalafil 5mg daily, getting the blood pressure and blood sugar under control with his PCP, thirty minutes of walking. Six months later he’s not depressed, he was never depressed, he was scared.

PDE5 inhibitors, and the daily-versus-PRN question

Sildenafil, tadalafil, vardenafil. Viagra, Cialis, Levitra. They all work the same way, which is to block an enzyme that breaks down the signal that tells blood vessels in the penis to relax. They don’t make desire. They don’t make erections out of nothing. They turn up the volume on what’s already there when arousal happens. If you take one and sit there watching the clock, nothing dramatic happens, which confuses guys who were expecting a switch. The pill doesn’t create desire, it amplifies what’s there, and if the desire isn’t there no PDE5 inhibitor in the world is going to fix that.

The practical differences are duration and dosing. Sildenafil lasts about four hours, kicks in at thirty to sixty minutes, gets blunted by a heavy meal. Vardenafil is similar. Tadalafil lasts up to thirty-six hours (which is where the “weekend pill” name came from) and has a daily-dose option at 2.5 to 5mg.

The daily tadalafil case is underused. For the guy who hates the planning, doesn’t want to take a pill and watch the clock, wants sex to feel spontaneous again, low-dose daily tadalafil is often the better answer than as-needed Viagra. It also helps with urinary symptoms in older guys, which is a useful side benefit. PRN makes more sense for younger guys with infrequent activity who don’t want a daily med. Both are reasonable, the daily one is the one that doesn’t get offered enough.

Worth knowing on contraindications: nitrates (the chest-pain drug class, nitroglycerin and its cousins) plus a PDE5 inhibitor can drop blood pressure dangerously, so don’t combine them. Severe cardiovascular disease where exercise itself is risky is a soft contraindication because sex is exercise, and a heart that can’t take the stairs probably can’t take the sex either. Outside of those, these drugs have one of the safer track records in medicine.

When PDE5 inhibitors aren’t enough

A lot of guys come in expecting Viagra to be a magic switch and discover it does maybe 60 percent of what they hoped. The drug is real and it works for most men with mild-to-moderate ED, but a real chunk of patients either don’t respond, can’t tolerate the side effects, or have ED severe enough that PDE5 inhibitors aren’t going to close the gap. The second-line ladder is where this conversation often goes sideways, because the wellness industry has noticed the gap and filled it with stuff ranging from “evidence-backed clinical option” to “we are inventing the trial on you and charging you five grand to be the patient.”

The honest hierarchy, roughly in order of how well-supported the evidence actually is:

Vacuum erection devices

Least sexy intervention in this category, also one of the most evidence-backed. A cylinder, a hand pump, a constriction ring. The pump pulls blood into the penis, the ring traps it. The 5th International Consultation on Sexual Medicine in 2024 reaffirmed VED (vacuum erection device, the cheap mechanical pump option) as effective across difficult-to-treat populations: diabetes, post-radical-prostatectomy, spinal cord injury. Combined with a PDE5 inhibitor it outperforms either alone. It’s also a $150 device, not a $1,500 procedure.

The reasons guys don’t actually use it are aesthetic and habitual. It requires planning. It’s not romantic. The erection lasts only as long as the ring is on, capped at 30 minutes. For couples who can integrate it, the results are real and durable, for couples who can’t, it ends up in a drawer after two weeks. The long-term attrition is high precisely because it works mechanically but loses the cultural fight to a pill.

Trimix and alprostadil (the injection option)

This is the part of the ladder that gets fewer Instagram ads and considerably more results. Self-injection into the side of the penis with a fine needle, fifteen to thirty minutes before sex. The medication relaxes the smooth muscle directly, bypassing the upstream signaling chain that PDE5 inhibitors depend on. Two formulations matter:

Alprostadil (prostaglandin E1, sold as Caverject or Edex) is the only FDA-approved injectable. Effective, studied since the 1996 NEJM trial. The downside is dose-dependent penile pain in about 30 percent of guys, which is why patients often move on to:

Trimix (alprostadil plus phentolamine plus papaverine) prepared at a compounding pharmacy. Not FDA-approved as a combination because nobody is going to run the trial that would get it approved, used widely anyway and endorsed by the 2018 AUA ED guideline as a reasonable second-line after an in-office test injection. Trimix has higher response rates than alprostadil monotherapy, smaller volume per dose, and considerably less pain because the alprostadil component is cut down. Real-world series put intercourse-capable rates around 80 to 90 percent. Wait, you can inject your own dick? Yeah, with a fine needle, fifteen minutes before sex, and once a guy gets past the first time it’s a non-event. It’s not the move for everyone, it’s the move that actually works for the guys it’s the right move for.

Side effects worth taking seriously: priapism (an erection that won’t go down after four hours, which is a urology emergency that you don’t just wait out at home), corporal fibrosis from repeated injections over many years, occasional bruising at the site, and the psychological reality that some guys are never going to self-inject regardless of how effective it is. The in-office test injection sorts out who can use it before anyone goes home with a vial.

Penile prosthesis, the surgical option

For guys with severe ED who haven’t responded to oral or injection therapy. Inflatable three-piece prosthesis is the standard, surgical implant of a hydraulic device the patient activates by squeezing a pump in the scrotum. Patient satisfaction rates in well-selected men run around 90 percent, which is the highest in this entire ladder. The procedure is real surgery with real recovery and a real complication profile (infection, mechanical failure over a decade or so, anatomic complications), and once you have a prosthesis the natural tissue gets remodeled and PDE5 inhibitors won’t work afterward. This is a one-way door. Urology owns this conversation, not psychiatry.

Shockwave therapy, the trendy one

Low-intensity extracorporeal shockwave therapy (Li-ESWT, the acoustic-wave thing being advertised by every men’s-health clinic right now) is the intervention getting the most marketing attention, and the evidence is actually genuinely interesting. The mechanism is plausible… low-energy acoustic waves applied to the penile shaft over six to twelve sessions stimulate small new blood vessel growth in animal models. A 2025 meta-analysis of 12 randomized trials covering 882 men with vasculogenic ED found significant improvement in standard ED scoring compared to sham. The effect is real, the safety profile is excellent, the durability is the open question because the effects fade after several months in many patients.

The AUA still calls it investigational. That’s worth understanding in plain terms: the trials are positive, the mechanism is plausible, but the trials are heterogeneous (different devices, different protocols, different patient selection) and we don’t yet have the long-term data we’d want before calling this standard of care. Most insurance won’t cover it. Cash pay runs $3,000 to $5,000 for a course, which is the part the marketing copy doesn’t lead with.

Honest read: it’s a reasonable option for the vasculogenic-ED guy in his 40s or 50s who’s failed PDE5 inhibitors, doesn’t want to inject, and is willing to accept investigational status and self-pay. It is not a first-line option, it is not a miracle, and the clinics charging $5,000 for a “stem cell plus shockwave plus PRP combo” are stacking marketing on top of marketing and the prescriber selling it that way is a damn liar.

PRP / “P-Shot,” mostly hype

Platelet-rich plasma injected into the penis, sold under brand names with extravagant claims. The trial base is thin. There’s exactly one well-designed randomized placebo-controlled study (Poulios 2021, 60 men, real improvement in PRP versus sham at six months). One trial is not a body of evidence. Subsequent attempts to replicate have been mixed. The mechanism is “growth factors do tissue regeneration,” which is hand-wavey enough to support any marketing claim somebody wants to make. Currently sold at $1,500 to $3,000 per session, often as a “package” because you can charge more if you bundle it.

If a clinic offers PRP and you ask them which trial they’re basing it on, they should be able to cite Poulios 2021 and tell you about its limitations. If they can’t… you’re paying for marketing wearing a syringe.

What doesn’t have the data yet

A short list of things being sold as treatments that aren’t quite treatments yet: stem cell therapy for ED (preclinical, no Phase 3 human data, sold at $5,000-plus regardless), proprietary-brand shockwave marketed as “regenerative” beyond what the physics can actually do, peptide injections for ED (BPC-157 and friends), and high-dose testosterone-precursor stacks pushed as “natural alternatives.” Maybe some of these mature into real treatments down the line, they aren’t there yet, and selling them as treatments instead of trials is dishonest. What your buddy at the gym told you about peptides probably came from a Reddit forum and an Instagram ad, in slightly different fonts.

Premature ejaculation, and the SSRI angle nobody talks about

Premature ejaculation is the other half of this conversation and it gets way less airtime, partly because it’s even more embarrassing to bring up and partly because there’s no advertised pill for it in the US the way there is for ED. Dapoxetine, a short-acting SSRI made specifically for PE, is approved in most of Europe and Asia but not here, so what American clinicians actually do is use off-label SSRIs. Sertraline 50 to 100mg daily, or paroxetine 20mg daily, both delay ejaculation as a side effect that happens to be useful in this context. Some guys do PRN dosing, taking paroxetine 20mg about four hours before sex, which works for some and not for others. Daily is more reliable.

Topical lidocaine sprays applied ten minutes beforehand are a reasonable adjunct, sometimes enough on their own. Behavioral techniques (stop-start, squeeze) work for some couples and are worth doing alongside medication, not instead of it.

The first conversation worth having is about what’s actually happening. A lot of guys who think they have PE are within the normal range and have absorbed an expectation from pornography that has nothing to do with how real human sex works. The clinical definition involves ejaculation within about a minute of penetration, consistently, with distress. If you’re going ten minutes and feeling like you should be going thirty, that’s a different conversation, and the answer to it probably isn’t more pills.

When the SSRI is the problem, not the solution

SSRIs and SNRIs cause sexual side effects in something like 50 to 70 percent of users. Delayed orgasm, lower libido, sometimes ED, sometimes no orgasm at all. This is the single most common reason guys quit antidepressants, and most of the time the prescriber doesn’t ask about it, so the patient just stops the medication and the depression comes back. Wait can you actually ask your prescriber about your erection problem? Yes, that’s literally what they’re there for, and if your prescriber gets weird about the question, get a different prescriber.

The rescue strategies, roughly in order of how aggressive they get: drop the dose if the depression is well-controlled (sometimes 25mg of sertraline is enough where 100mg was overkill), switch to bupropion (Wellbutrin, the antidepressant that doesn’t cause sexual side effects and sometimes mildly improves function), add bupropion 150 to 300mg on top of the SSRI if switching isn’t an option, add as-needed sildenafil specifically for the SSRI-induced ED (which has reasonable data behind it). None of these are perfect. All of them are better than silently quitting your medication and getting depressed again four months later.

Who actually handles this

Here’s the part the system gets backwards, almost none of this needs a urologist. A men’s-health clinician handles the whole vascular ladder short of surgery, the PDE5 inhibitors and the daily low-dose tadalafil, the vacuum device, the Trimix or alprostadil injections with the in-office test injection that sorts out your dose before you ever take a vial home, the shockwave course if you’re genuinely a reasonable candidate for it, and the testosterone workup and replacement when the numbers and the symptoms actually line up. That’s men’s health, and it isn’t a referral you sit on a two-month waitlist to earn.

Urology comes in at the surgical and structural end, the penile implant, Peyronie’s when there’s real curvature or palpable plaque or pain, and anything the workup turns up that needs a scope or an operating room. Priapism, the erection that won’t quit after four hours, is the one genuine emergency in here, and it goes straight to the ER rather than onto a calendar. Everything short of surgery, though, is a conversation you can have with a clinician who treats men, and you don’t have to earn your way to it through a specialist gate that was never actually required in the first place.

Psychiatry comes in when performance anxiety has built on top of what started as a physical problem, when SSRIs caused the issue, when depression or anxiety is the actual driver, when the problem started after a specific event (a heart scare, a divorce, a job loss). Sometimes it’s both, and the right answer is two clinicians who are actually talking to each other instead of pretending the other one doesn’t exist.

What I’d push back on hardest is the assumption that this is a problem you have to live with quietly because mentioning it is embarrassing. The number of guys who fix this in a few months after sitting on it for far too long is not small. The hard part is the first sentence, which is the sentence you’ve been avoiding. After that it’s just medicine, and honestly the person across the desk has heard the question before, probably ten times today, and is genuinely not going to think anything weird about you for asking it.

The downtown plumbing is an early-warning system. Pay attention to it before the same physiology starts knocking on a bigger artery.

One more thing on the autonomy piece, because it matters. If you want the prescription, you get the prescription. I’m a provider, not a parent. My job is to lay out the honest version of what’s likely to work and what the trade-offs are, your job is to decide what you want to do with that information. The appointment isn’t mine, it’s yours, and “talk to your wife about the sex thing” is the harder homework here than the prescription itself, but the prescription gets written either way.

Sources

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