Erectile disorder and premature ejaculation — assessment and management (MEQ)

(i) Formulation. Acquired, likely generalised erectile disorder with strong organic contribution: progressive course, absent morning erections, diabetes, and vascular (angina) risk. Performance anxiety and depressive illness may amplify failure (mixed model). Short latency when erection is partial is consistent with acquired PE secondary to ED and anticipatory rushing — not necessarily lifelong primary PE alone. Sertraline may further alter desire/orgasm timing; depression itself also impairs sexual function.[2][3][5][6]

(ii) Assessment priorities. Structured sexual history (phase map, lifelong/acquired, situational factors); IIEF for ED severity; estimated IELT and PE distress; full medication/substance list; angina pattern and all nitrate products including GTN spray; diabetes control; smoking/alcohol; suicide risk linked to shame; partner factors. Baseline labs as indicated (HbA1c already high — optimise; lipids; morning testosterone if hypogonadism clues). Coordinate GP/cardiology for CV risk.[2][5]

(iii) PDE5 inhibitor suitability. Sildenafil has robust efficacy evidence for ED but is contraindicated with concurrent nitrates (including GTN spray) because of severe hypotension risk. Do not prescribe PDE5i while nitrate therapy remains. Arrange cardiology/GP review of anti-anginal regimen and overall CV fitness for sexual activity before any future PDE5i trial; educate him not to self-source online PDE5i while holding GTN.[1][2]

(iv) Ejaculatory and antidepressant issues. ISSM pearl: treat ED first when PE coexists — improving erection quality may reduce rushed ejaculation. Behavioural methods (stop-start/squeeze, sensate focus, couple work) once medically safer. Do not start PE-directed SSRIs uncritically while already on sertraline with incomplete depression response — consider whole-regimen review (dose, switch options, sexual SE counselling) rather than stacking serotonergic agents blindly. Dapoxetine only where licensed and after ED/nitrate issues resolved.[3][4][6]

(v) Disposition and safety-net. Shared care with GP for diabetes/CVD optimisation; cardiology before PDE5i; psychosexual pathway; psychiatric follow-up for depression and sexual function; crisis contacts if suicidal ideation emerges; urgent care advice for chest pain during sexual activity and for priapism if future erectile drugs are used. Written plan: no PDE5i with GTN.[1][2][6]