What is the diagnosis and management for a 31-year-old male with vitiligo, who engages in weight training 5 days a week, and experiences semi-hard erections and difficulty ejaculating during intercourse, but is able to ejaculate after prolonged masturbation?

Diagnosis: Erectile Dysfunction with Delayed Ejaculation

This patient has erectile dysfunction (ED) manifesting as inadequate rigidity ("semi-hard penis") with secondary delayed ejaculation (DE), requiring intensive stimulation to achieve orgasm. The ability to ejaculate with prolonged masturbation but not during intercourse strongly suggests ED as the primary problem, with DE developing secondarily due to insufficient penile rigidity and the need for intense stimulation to maintain erection 1.

Clinical Reasoning

Primary Problem: Erectile Dysfunction

• The "semi-hard" erection is the key diagnostic feature - this indicates inadequate penile rigidity for satisfactory sexual performance 1
• The 30+ minute inability to ejaculate during intercourse, but ability after 45 minutes of masturbation, suggests the patient requires more intense stimulation than partnered sex provides 1, 2
• When ED and ejaculatory complaints coexist, ED must be treated first - many patients with ED develop secondary ejaculatory dysfunction due to anxiety about maintaining erections or the need for intense stimulation 1, 2

Secondary Problem: Delayed Ejaculation

• DE is defined as difficulty achieving sexual climax despite adequate stimulation 1, 3
• The pattern here (can ejaculate with prolonged masturbation but not intercourse) suggests the ED is preventing adequate stimulation during partnered sex 1, 3
• This is likely a secondary phenomenon that may resolve once erectile rigidity improves 1

Diagnostic Evaluation

Essential History Components

• Document erectile rigidity on a scale - determine if erections are sufficient for penetration and maintenance 1, 2
• Assess morning erections and rigidity during masturbation versus partnered sex 1, 2
• Determine onset: lifelong versus acquired (this appears acquired given his active lifestyle) 1, 2
• Screen for performance anxiety - the prolonged intercourse attempts may be creating a cycle of anxiety worsening ED 1
• Evaluate relationship factors and partner dynamics 1, 2

Physical Examination

• Focused genital examination to identify anatomical abnormalities, penile plaques, or testicular abnormalities 1, 2
• Assess for signs of hypogonadism (body hair distribution, gynecomastia, testicular size) 1
• Cardiovascular examination given ED's association with vascular disease 4

Laboratory Testing

• Morning total testosterone level - essential in all men with ED 1
• Thyroid function testing - recommended given his vitiligo diagnosis due to high prevalence of autoimmune thyroid disease in vitiligo patients 1
• Consider fasting glucose/HbA1c and lipid panel given ED's association with metabolic syndrome 4
• No routine testing needed for the ejaculatory component alone unless history/exam suggests specific pathology 1, 2

Management Algorithm

Step 1: Treat Erectile Dysfunction First

The ED must be addressed before tackling the ejaculatory issue 1, 2. Treatment options include:

First-Line: PDE5 Inhibitors

• Start with sildenafil 50mg, tadalafil 10mg, or vardenafil 10mg taken 1 hour before sexual activity 1
• Titrate dose based on response and tolerability 1
• This is the most appropriate initial approach for a young, active man without contraindications 1

Address Modifiable Factors

• Screen for performance-enhancing substance use - given his intensive weight training (5 days/week), assess for anabolic steroid use which can cause ED and ejaculatory dysfunction 1
• Evaluate for overtraining syndrome which can affect sexual function 1
• Reduce performance pressure - the 30-minute intercourse attempts may be creating anxiety that worsens ED 1

Step 2: Reassess Ejaculatory Function

• Once erectile rigidity improves, the delayed ejaculation will likely improve or resolve 1
• If DE persists despite adequate erections, then consider it a separate problem requiring specific management 1, 3

Step 3: If Delayed Ejaculation Persists

Behavioral Approaches

• Reduce masturbation frequency and intensity to decrease stimulation threshold 1, 3
• Partner involvement in treatment planning 1, 2
• Consider sex therapy referral if behavioral modifications fail 1, 3

Pharmacologic Options (if needed)

• No FDA-approved medications exist for DE 1, 3
• Off-label options include bupropion, buspirone, or cabergoline, but evidence is limited 1, 3
• These should only be considered after ED treatment and behavioral approaches have been optimized 1, 3

Vitiligo Considerations

Impact on Sexual Function

• Vitiligo can cause sexual difficulties through psychological mechanisms - low self-esteem, shame, and embarrassment may contribute to sexual dysfunction 5
• Large depigmented areas and genital involvement are predictive of sexual disorders 5
• Assess the psychological impact of vitiligo on this patient's sexual confidence 1, 5

Thyroid Screening

• Check thyroid function given the high prevalence of autoimmune thyroid disease in vitiligo patients 1
• Hypothyroidism can independently cause ED and ejaculatory dysfunction 1

Critical Pitfalls to Avoid

• Do not treat the ejaculatory complaint first - this will fail if the underlying ED is not addressed 1, 2
• Do not assume this is primary delayed ejaculation - the ability to ejaculate with masturbation indicates the ejaculatory mechanism is intact 1, 3
• Do not overlook anabolic steroid use in a young man with intensive weight training and sexual dysfunction 1
• Do not miss thyroid disease - screen given his vitiligo 1
• Do not order extensive laboratory testing for the ejaculatory component unless ED treatment fails 1, 2

Expected Outcomes

With appropriate ED treatment, both erectile rigidity and ejaculatory latency should improve significantly 1. If the ejaculatory dysfunction persists despite restored erectile function, then it represents a separate primary problem requiring specific intervention 1, 3. Patient and partner satisfaction should be the primary outcome measure 1, 2.