Erectile and ejaculatory disorders — structured clinical viva

PDE5i "failure." Sildenafil requires sexual stimulation to work (NO–cGMP pathway) and is undermined by heavy alcohol, incorrect timing, and performance anxiety/high sexual inhibition. Re-education, alcohol reduction, and adequate trial conditions often convert "non-responders" into responders; true non-response prompts medical review and second-line urology options, not automatic prosthesis talk on visit one.^[1][4][6]

Lifelong PE. Short IELT from early sexual life plus inability to delay and distress meets ISSM-style lifelong PE. Behavioural techniques and PE-directed pharmacotherapy (daily SSRI strategies or dapoxetine where licensed) are evidence-aligned; couple therapy addresses separation threat.^[2][5]

Escitalopram paradox. SSRIs delay orgasm/ejaculation (useful for PE, harmful as an unplanned side-effect). Here masturbation is delayed but partnered PE persists — anxiety, rushing, and relationship threat maintain short partnered latency. Do not assume the SSRI has "fixed" PE; integrate behavioural PE work and consider whether panic regimen can be optimised without abandoning anxiety control.^[3][2]

Integrated plan. (1) Medical suitability and nitrate check before any further PDE5i; teach correct use. (2) Alcohol counselling. (3) PE behavioural package and consider dedicated PE pharmacology if needed after clarifying the SSRI plan. (4) Panic/depression monitoring if changing serotonergic agents. (5) Couple session for shame and separation crisis. (6) Safety-net suicidality if separation proceeds.^[2][3][6]