Introduction The term impotence has traditionally been used to describe the inability of the male to attain and maintain an erection adequate for sexual intercourse. Although the term has been used for centuries, as will be described in this article, it generates much confusion and has been replaced by ‘erectile dysfunction’ since 1992 [1]. This then differentiates the problem from the many other processes that are involved in male sexual function. This review will use the term impotence because historically it is the term that is found in the literature. Many people believe that impotence is a modern curse to man. In 1940, Stekel [2] said that ‘Impotence is a disorder associated with modern civilization’. However, man's preoccupation with potency, or the lack thereof, has been present through the ages. The word impotence is derived from the Latin word impotencia, which literally translated means lack of power. The term was first used by Thomas Hoccleve (1370–1454) in 1420, in his 5500‐verse poem, ‘De Regimine Principum’ (the Government of Princes): ‘ Hir impotence, Strecchith naght so fer as his influence ’ [ 3 ]. At the time he used it to mean want of strength. It was in 1655 that the use of impotence to mean loss of sexual power was first encountered. Thomas Fuller (1608–1661) wrote in ‘The Church History of Britain’: ‘ Whilest Papists crie up this, his incredible incontinency: others uneasily unwonder the same by imputing it partly to impotence afflicted, by an infirmitie ’ [ 4 ]. This article describes the aetiology of and beliefs about the condition, and the developments of treatments for impotence over time

Impotence in ancient times The oldest reference to impotence was made in the Samhita of Sushruta, around the eighth century BC in India. An attempt was made to describe the causes of the condition, suggesting at least four, i.e. voluntary, congenital, praecox and diseases of the genital organs [5]. In fact, the ancient Hindus believed that impotence could also be of mental origin, from intercourse with a distasteful woman: ‘ Cessation of the sexual desire owing to the rising of the bitter thoughts of recollection on the mind, or a forced intercourse with a disagreeable woman (who fails to sufficiently rouse up the sexual desire in the heart of her mate), illustrates an example of mental impotence ’ [ 6 ]. Many interesting remedies were recommended within the Samhita: ‘ Powders of sesame, Masha pulse, and S’ali rice should be mixed with Saindhava salt and pasted with a copious quantity of the expressed juice of the sugar cane. It should then be mixed with hog's lard and cooked with clarified butter. By using this Utkarika a man would be able to visit a hundred women ’. Others ways of visiting a hundred women included eating the testes of a goat, either by boiling the testes in milk and adding sesame seeds and lard of a porpoise, or by mixing the testes with salt, powdered pepper fish and clarified butter. To enable an 80‐year‐old man to be as sexually vigorous as one in his youth, the following was recommended: ‘ Powders of dried Amalaka successively soaked in its own expressed juice should be licked with honey, sugar and clarified butter, after which a quantity of milk should be taken ’ [ 5 ] . Not all remedies suggested by Sushruta were to be ingested: ‘Clarified butter should be boiled with eggs or testes of alligators, mice, frogs and sparrows. By lubricating the sole of the feet with this a man would be able to visit a woman with undiminished vigour as long as he would not touch the ground with his feet’ [ 6 ] . The Aqrabadhin of Al‐Kindhi, believed to be an ancient Arabic medicinal formulary dating back to the 7–9th century BC also prescribes a treatment for impotence: ‘ Throw in good oil of jasmine and asafoetida and leave for some days. Then the male organ is oiled with that oil of jasmine at the time of intercourse ’ [ 7 ]. Traditional Chinese medicine has its roots in the concept of Yin (negative, dark and feminine) and Yang (positive, bright and masculine), two opposing but complementary sides of nature. Using this framework for medicine, the ancient Chinese believed that disease was caused by an imbalance of the two states. By the time a man is aged 60 years, the life‐providing power of Yin has declined to a very low level and therefore the man was expected to be impotent [8]. Additionally, the physical manifestation of healthy Yang is the erection and healthy erectile function. Imbalance of the Yang in traditional Chinese medicine results in difficulty achieving and maintaining an erection, or premature ejaculation. On the other hand, the Yin must also be healthy and sufficient for adequate fertility, sperm production and sperm quality. Thus, if the Yin is affected, abnormalities of ejaculation and infertility may ensue [9]. The oldest Chinese text, Huang‐Ti Nei‐Ching (The Yellow Emperor's Classic of Internal Medicine) is a documentation of traditional Chinese medicine during the time of the Yellow Emperor's (Huang‐Ti) rule from 2697 to 2595 BC. In this text, the philosophy of impotence and its treatments are discussed. It lists a potion with 22 ingredients that the emperor himself drank, and ‘mounted 1200 women and achieved immortality’[10]. In Ancient Egypt, impotence was considered to be of two types: a natural cause where a ‘man is incapable of accomplishing the sex act’ and to have a supernatural element such that evil charms and spells could cause impotence [11]. The Egyptian Papyrus Ebers, a medical Egyptian document dated 1600 BC, lists 811 prescriptions for various ailments, including impotence. In that, baby crocodiles’ hearts were mixed with wood oil to the appropriate consistency, and this then be smeared into the husband's penis to restore his potency [12]. Another remedy consisted of an oral combination of 37 substances. Only some of these have been identifiable: carob, juniper, pine, salt, various oils and watermelon [12]. In Greek mythology impotence in adult life was caused by sexual anxiety in childhood. In one example, King Phylacus of Phylace asked his physician, Melampus, to cure his son, Iphiclus, of impotence. Melampus established that Iphiclus had seen his father come towards him with a blood‐stained gelding knife when he was a child, and was terrified that his father was going to castrate him. This fear as a child manifested as impotence in adulthood. Melampus agreed to cure Iphiclus in return for some cattle, and told the King to scrape off the rust from the knife, which was buried in a tree, and put it into a cup of wine. When Iphiclus drank this wine, he was cured of his impotence [13]. Impotence was also considered to be caused by a divine curse; this is a recurring theme as a cause of impotence throughout time. In another classical tale, King Amassis of Egypt married Ladice, a Greek woman. However, every time they attempted intercourse, they failed. Instead, the King turned to his numerous other wives for sexual gratification. Meanwhile, his impotence only with Ladice was considered to be a curse, and she was condemned to death. In her defence she prays to Aphrodite, the goddess of sexual love and beauty, and asks for her marriage to be consummated. Her prayers were answered and the curse lifted [14]. Impotence is also mentioned in the Old Testament. King Abimelech of Gerar is believed to have become impotent as punishment for taking Abraham's wife, Sarah, who was introduced to him as Abraham's sister: ‘ But God came to Abimelech in a dream by night and said to him: Behold, thou art but a dead man, for the woman which thou has taken for she is a man's wife ’ (Genesis 20:3). The Bible also suggests a cure for King David's impotence: ‘ Now King David was old and stricken in years; and they covered him with clothes, but he got no heat. Wherefore his servants said unto him, Let there be sought for my lord the king a young virgin: and let her stand before the king, and let her cherish him, and let her lie in thy bosom, that my lord the king may get heat ’ (First Book of Kings 1:1). In his works, Hippocrates devotes considerable time to the subject of impotence; he discusses the aetiology of impotence: ‘ In Europe there is a Scythian race, called Sauromatae, which inhabits the confines of the Parks Maeotis, and is different from all other races ’ [ 15 ]. ‘. . . there are many eunuchs among the Scythians, who perform female work, and speak like women. Such persons are called effeminates. The inhabitants of the country attribute the cause of their impotence to a god, and venerate and worship such persons, every one dreading that the like might befall himself . . . But I will explain how I think that the affection takes its rise’. Hippocrates continues to explain how this race spend most of their time on horseback, and from the continued exercise, ‘are seized with chronic deflexions in their joints’. It seems that in an attempt to treat this condition they actually caused impotence: ‘ . . . open the vein behind either ear . . . To me it appears that the semen is altered by this treatment, for there are veins behind the ears, which if cut, induce impotence ’ [ 16 ]. By the Middle Ages, and for many years thereafter, impotence was believed to be caused by witches [17]. In the ninth century, Hincmar, the Archbishop of Rheims, was the first to make the connection between witchcraft and impotence. In the preface of Daemonologie, King James I of England asserts the power of witches to weaken ‘the nature of some men, to make them unavailable for women’[18]. Many believed that tying a magic knot into a ring or a key using cord or a strip of leather, and then hiding it, caused impotence of the groom at a wedding. This was known as the ‘magic ligature’. The impotence would last until the knot was found and undone by the person who cast the spell. A countermeasure against the ligature involved the groom urinating through the wedding ring the night before the wedding [19]. Thomas Aquinas (1225–1274), a mediaeval theologian, established a difference between impotence with one partner, known as ‘ligature’, and ‘frigiditas’, where the man was thus affected with every woman. He also wrote a famous treatise (Quaestiones Quadlibetales[20]) in which he states the following: ‘ The Catholic faith maintains that demons are something and that they can do harm by their operations and impede carnal copulation ’. The Malleus Maleficarum (the hammer of witches), a major textbook for witch hunters, was first published in 1486. The book extensively documents how witches were able to make men impotent or indeed cause the disappearance of the penis altogether. The manual also suggests remedies by the church for those who were seemingly affected by this: ‘ Try to persuade the witch to restore it. If persuasion does not work, use violence ’ [ 21 ]. In one example cited in the Malleus Maleficarum, a young man, who had parted ways with his girlfriend, lost his penis through sorcery, such that ‘he could see or touch nothing but his smooth body’. In his sadness, the young man drinks wine at an inn and meets an astute woman who advises him: ‘If persuasion is not enough, you must use some violence, to induce her to restore you your health’. The man finds the witch in question and prays for her to return the health of his body. When she maintained her innocence: ‘he fell upon her, and winding a towel tightly round her neck, choked her, saying: “Unless you give me back my health, you shall die at my hands.” Then she, being unable to cry out, and with her face already swelling and growing black, said: ‘Let me go, and I will heal you.’ and the young man, as he plainly felt, before he had verified it by looking or touching, that his member had been restored to him by the mere touch of the witch’ [ 21 ] . Here, sexual assault is shown as a cure for impotence. From the 13th to the end of the 17th century, particularly among the upper classes, impotence was the only grounds for divorce. Indeed, in canonical (ecclesiastical) law, it was considered a deadly sin for an impotent man to marry, although there was no legal bar for him to marry. In the most extensive study to date of the legal history of impotence, Pierre Darmon [22] describes the manner in which those suffering from the condition were persecuted: ‘The impotent man commits an act of larceny, profanes a sacrament, and indulges in an inhumane, cruel and dangerous act’. Many of the assumptions he makes about the French ancient regime held true for Britain. The only means of proof was to sequester the couple behind curtains and ask them to have intercourse in front of expert witnesses, although the lack of exact definitions and measurements of impotence led to much ambiguity. Juries occasionally required that the man ejaculated in public, whereas others inspected the hymen [22]. These trials attracted a great deal of publicity, and James Hammerton succinctly describes the public's appetite for such domestic conflict [23]. One famous case involved Don Carlos II (1661–1700), the last of the Spanish Hapsburgs, who was unable to provide a Spanish heir through presumed impotence. When his first wife, Marie Louise, told the French Ambassador that she could not have children, he obtained a pair of Carlos's drawers, and ordered physicians to examine them for traces of sperm. The physicians were unable to agree in their findings, and exorcisms were performed. Carlos remarried, but his second wife, Maria Ana, was still unable to produce an heir. This eventually led to the War of Spanish Succession. Impotence trials became more frequent from the end of the 16th century, with reports on trials widely distributed. Such public trials continued until 1670, after which they were thought to be too scandalous, and were therefore abolished. Speculation about the causes of impotence continued throughout the centuries, with the ultimate focus on divine providence rather than physiology. This continued until the 19th century, when authorities promoted a new theory, claiming that impotence was a male disorder caused by insufficient self‐control and sexual misconduct. At this time, the high incidence of impotence among Victorian men was attributed to the voluntary loss of semen through masturbation and involuntary loss, termed spermatorrhoea [24]. There were some physicians, e.g. T.F. Lockwood, who doubted this as the cause [25]: ‘I cannot believe that masturbation is anything short of a natural process intended to exercise and develop the sexual capacity in early life’. Instead he argued that it was the abuse and overindulgence that created subsequent impotence. The implications of impotence caused considerable anxiety in Victorian society, and much was written on the subject, many pamphlets were distributed, and parents warned their young sons not to practise such evils. Treatments included quinine, opium and digitalis, and sponging with cold salt water at 5 o’clock in the morning [26]. For more difficult cases, physicians resorted to scarification of the perineum, followed by suction cups that drew out several ounces of blood, and the passage of a bougie smeared with a mercurial ointment upon the mucous membrane of the urethra. This was left for 5–10 min in the belief that the pressure would reduce the congestion in the vessels of the urethra [27].

Science and impotence ‘If a woman's hand, which is the best of all remedies, is not good enough to cure the flabbiness of a man's penis, the other remedies will do little’ [ 28 ] . Unfortunately, this quote by the Frenchman Nicholas Vennette (1633–1698) summarized the general view of both the public and the medical profession towards impotence and its treatments, until knowledge of anatomy, physiology and the pathology of impotence were discovered. Leonardo da Vinci (1452–1519) commenced the interest in the anatomy of the penis: ‘The origin of the penis is situated upon the pubic bones so that it can resist its active force on coitus. If this bone did not exist the penis, in meeting resistance, would turn backward and would enter more into the body of the operator’ [ 29 ] . Many believed that it was air that led to the stiffness of the erect penis, and da Vinci challenged this by stating that the rigid penis was red because of the abundant blood, and the limp and weak penis was white through lack of it. In 1573, Varolio described a basis for erection; he stated that two muscles, the ischiocavernosus and the bulbocavernosus, constricted the root of the penis, thereby impeding the venous return. Taking this theory a step further, a Dutchman, Regnier de Graaf (1641–1673) noted the following in 1668 when he injected fluid into cadavers: ‘. . . for if fluid is introduced into the hypogastric artery that leads to the corpora nervosa, the penis is immediately erected, and this more or less so in proportion as you drive the fluid into the corpora nervosa with more or less force’ [ 30 ] . The first study of electronically induced erections was over a century ago, when Eckhard showed an erection in canine models after stimulating the nervi erigentes. His interpretation was that these autonomic nerve fibres formed the pelvic plexus and supplied vasodilator fibres to the penis [31]. Lovén then observed that after Eckhard's stimulation of the nervi erigentes, the arterioles of the cavernous tissues dilated, leading to increased arterial inflow [32]. The start of surgical treatments for impotence, in 1873, began a more detailed understanding of the process of erection. In Italy, Francesco Parona noted gross varicosities of the dorsal penile vein in a 30‐year‐old impotent man, and believed that these varicosities were draining blood away from the penis at a much faster rate than normal. Parona sclerosed the vein using hypertonic saline, and the patient reported successful intercourse 5 days after the treatment [33]. In 1902, Wooten from Texas noted that impotence was the loss of tissue tonicity, and thus the veins of the penis were dilated. He suggested that a cure for impotence was therefore ligation of the dorsal vein of the penis [34]. In 1908, the professor of surgical disease of the genitourinary organs at the University of Illinois, Frank Lydston, claimed that many physicians had failed in this procedure, the reason being that unlike him, the others were not ligating the deep dorsal vein of the penis, but instead only the superficial vein. He recommended ligation of all veins found. Lydston had performed over 100 dorsal vein ligation procedures and 53% of his patients were cured of impotence. He attributed the success of his procedure to enlargement of the penis caused by mechanical obstruction to the venous outflow [35]. With Wooten and Lydston came the realisation of the role of the vasculature in the process of developing an erection. Hinman further developed this theme of occluding venous outflow during tumescence. In 1914 he stated that contractions of the ischiocavernosus and the bulbospongiosus muscles compressed afferent veins, and completed the erectile process. In addition, he described an intrinsic method for venous occlusion in the smooth muscle fibres that are distributed throughout the penile erectile tissue [36]. In the late 19th and early 20th centuries, venous occlusion was thought to be the predominant mechanism for erection, until Howell summarized the available hypotheses and introduced the role of the arterial system [37]. What is interesting is that the development of the vascular theory of the erectile process was paralleled with the start of the surgical treatment for impotence. In 1935 Oswald Lowsley conducted a series of experiments on dogs in the New York Hospital animal laboratory. He ablated the ischiocavernosus and bulbocavernosus muscles, and found that the dogs were unable to obtain an erection. When he plicated these muscles with several interrupted ribbon‐gut mattress sutures, erections occurred more easily and frequently, and if the plication was too tight, priapism occurred [38]. In 1936, the report of this operation in 51 patients was published, with excellent results in 31 [39].

Endocrinology, transplantation and the discovery of testosterone The first theoretical reflections of the endocrinology of penile erections came with the French neurologist Charles Edouard Brown‐Séquard (1817–1894), the son of a Philadelphia seaman. In 1889, at the age of 72 years, Brown‐Séquard injected himself with an extract from the testicles of dogs and guinea pigs [40]. He reported an increase in his physical and mental abilities, a better stream of urine and the relief of constipation. Brown‐Séquard had inspired physicians around the world to investigate the nature of this compound, and by the end of 1889 over 12 000 physicians were administering this new ‘Elixir of Life’[41]. In 1902, Ancel and Bouin in France ligated the ductus deferens in rabbits and noted atrophy of the seminal epithelium. However, the Leydig cells remained unchanged, and many of the animals appeared to have increased sexual activity [42]. This led the way for Eugen Steinach (1861–1944) a Viennese physiologist, who further investigated the effects of vasoligation in bulls, rams and senile rats. In 1920 he gained world‐wide acknowledgement for his theory that animals became rejuvenated after the ‘Steinach operation’ or the autoplastic treatment of ageing [43]. The procedure was popular for at least the next two decades, and Sigmund Freud and William Yeats are believed to have undergone the Steinach operation [44]. It was in 1936 that Paul Niehan (1882–1971), a Swiss genitourinary surgeon, first noted that this procedure could actually be used to correct impotence [45]. From 1935, the rejuvenation operations lost their appeal, mostly because androgens were introduced. The story of testicular hormones is an old one, stemming from organotherapy. In 1767 John Hunter was the first to transplant testicular tissue from a cock into the abdominal cavity of a hen, although he observed no systemic effects [46]. In 1918, Serge Voronoff (1866–1951), a Russian living in Paris, announced that transplanting testicular tissue from a monkey into a human could restore youth to a man [47]. The same year, Victor Lespinasse, professor of genitourinary surgery at North‐western University, treated impotence by oral glandular extracts. This too was not a new concept, as oral organotherapy had been used as an aphrodisiac for centuries (see below). When this failed, Lespinasse grafted slices of human testicles taken from fresh cadavers into the rectus muscle of impotent men. He believed that most cases of impotence in middle‐aged men were caused by a failure of hormone secretion, and reported positive results after several weeks, although these were transient [48]. Leo Stanley, a physician working at the San Quentin Prison in California, performed 1000 testicular substance implantations into 656 prisoners under his care. Unlike Lespinasse, Stanley used the testicles of goats, rams, boars or deer. He cut the testicles into strips of such a size that he could put them into a pressure syringe for injection under the skin of the abdomen. He reported a marked improvement in impotence [47]. The benefits of organotherapy were rapidly adopted by the pharmaceutical industry, and the race was on to isolate the substance responsible for the reported effects. In 1935, a new hormone was identified in the Netherlands by a group backed by the Organon Company, and the term testosterone was coined for the first time (testo = testes, ster = sterol, one = ketone) [49]. Later that year, two groups artificially synthesized testosterone, thereby beginning the industry for artificial androgens and replacing mainstream organotherapy. Of course, their use as oral aphrodisiacs continues in society even today.

Aphrodisiacs Aphrodisiacs take their name from Aphrodite, the Greek goddess of love, and have been used throughout history in an attempt to increase libido. Mandrake (Mandragora officinarum), a member of the potato family, has been used as an aphrodisiac since Old Testament times: ‘He shall sleep with thee this night, for thy son's mandrakes.’ (Genesis 30:15). Pliny, an ancient Greek in the 1st century AD, noted that the root of the plant was in the form of the human genitals, and thus another aphrodisiac effect of mandrake was believed to be ‘sympathetic’ magic. The Romans believed in organotherapy as a cure for their impotence. Thus, many men would consume the sexual organs of virile animals such as rabbits, or dried tiger's penises, which is still served as a soup in Taiwan and South Korea (costing about $350 for a bowl!) and hormonal secretions of animals: ‘ The semen of virile young men should be mixed with the excrement of hawks or eagles and taken in pellet form ’. The ancient Chinese also used animal genitals as a method of increasing potency. Deer have always been popular for organotherapy, and many would drink the blood of deer or eat deer penises, a delicacy even today. Aristotle was the first person to mention cantharides as an aphrodisiac. The active ingredient, cantharidin (hexahydro‐3,7‐dimethyl‐4,4‐epoxyisobenofuran‐1,3‐dione) is extracted from the dried and powdered bodies of the blister beetle, also known as the Spanish Fly. Livia, the wife of the Roman Emperor Tiberius, used to feed cantharides to other members of the imperial family so that they might commit sexual indiscretions, which would create material for blackmail [50]. Many other bizarre animal‐based aphrodisiacs have been used over the course of time; snake blood, the melted fat of a camel hump (used to lubricate the penis before intercourse) and leeches. The last are kept in a bottle, which is placed in a warm and dark place, until the leeches become a single mass. This concoction is then massaged into the penis [50]. There are many reasons why certain foods have evolved as aphrodisiacs. In some countries they gained their reputation as aphrodisiacs through mis‐translations and linguistic origins. For example, vanilla, considered a powerful aphrodisiac, is the diminutive of the Latin term vagina [51]. Another reason is that certain substances, e.g. chillies and spicy foods, evoke the same physical response as sexual intercourse, i.e. sweating, burning and distraction [52]. Other foods have their aphrodisiac property attributed by appearance and similarity to the genital organs. The Doctrine of Signatures during the time of the Saxons states that ‘every plant that is of use to man has been marked by God in a way that reveals its intended use’. Substances such as eggs, sunflower seeds and bulbs that resemble seeds or semen were naturally also believed to have powerful sex‐enhancing abilities. Hence, oysters that have a similar texture and resemble closely the female sexual organ, ginseng that loosely translated means ‘man‐like’, avocado, cucumbers and carrots, the rhinoceros horn, which resembles an erect penis and is popular in Chinese and Korean culture, have all made historical claims for increasing potency [50]. Many sea‐foods, but especially fish, are thought to be powerful aphrodisiacs. The association with Aphrodite, who was born at sea, lends credence to this theory [53]. There is a large industry marketing aphrodisiacs in society even today.

Prosthetic treatments Currently many patients with organic impotence are treated with prosthetic implants. However, the development of this form of treatment began with plastic reconstruction of the penis after amputation [54]. Gillis was the first to reconstruct the penis for micturition, but Professor Nicolai Borgoras was responsible for the first penile reconstruction adequate for both micturition and sexual intercourse, using rib cartilage in a tube skin graft [55]. A fortuitous observation of a bone in the penis of many animals, called the os penis, os priapi or baculum, and thought to assist them in the erectile process, was the reason for the use of rib cartilage. Bett [56] provides a detailed review of the baculum in many animals; in the whale, it is 2 m long and in the walrus 55 cm long. The location of the bone can vary considerably, such that in the dog it is a channel for the urethra, while in the bear and wolf it is essential for intercourse, as a result of their poor erectile tissue. Bett notes that the classification of the squirrel family is based on their having marked differences in their baculum. In one variety the baculum is very sharp and has probably evolved to perforate a resistant hymen. There is no evidence that man has ever possessed such a structure. Unfortunately Bogoras’ implant was unsuccessful because it was reabsorbed after several months. In 1948, Bergman et al.[57] reported a case of penile reconstruction using a rib graft, with successful postoperative intercourse. Again, within years, the cartilage was almost totally reabsorbed. The search for an appropriate synthetic material began, and in 1950 Peter Scardino implanted synthetic material into one patient, although he did not publish the work [54]. In 1952, Goodwin and Scott used specially shaped acrylic splints as penile implants to treat impotence in five patients. They were placed between the corpora cavernosa. In their results, the authors make reference to the previous work of Scardino [58]. By the 1960s, the problems with the intercorporeal placement of implants were becoming evident, and Beheri in Cairo began placing two polyethylene prostheses, one into each corpora. In 1966 Beheri published his experience of this technique in over 700 patients he had treated in this manner for impotence [59]. The technique was most clearly described by Pearman in 1967, when he reported the use of a Silastic prosthesis that was placed between Buck's fascia and the tunica albuginea. This caused patients a great deal of pain, and as a result Pearman changed his technique and began placing the implants intracavernosally, using Hegar dilators to dissect the space [60]. Hence the material for implants and the exact location were described, making this form of treatment more popular. The 1970s saw further developments in prostheses to what is currently available today. In 1973, Small et al.[61] developed the Small‐Carrion device, consisting of paired sponge‐filled silicone implants placed intracavernosally. The main concern with patients was the semblance of a permanent erection as the rods were semi‐rigid. This was overcome with the ‘Flexi‐Rod’ hinged prosthesis that allowed the penis to flex in the pubic region [62]. In parallel with the development of rod prostheses there emerged a new concept, using inflatable silicone cylinders. In 1973, Scott et al.[63] described a prosthesis consisting of two cylindrical Dacron‐reinforced silicone bodies, and an external reservoir, positioned behind the rectus, that was controlled by subcutaneous pumps in the scrotum. For many years after this was the most common inflatable implant. More recently, self‐contained erectable prostheses, e.g. the Flexiflate (Surgitek) and Hydroflex (American Medical Systems, Minnesota, MN) have entered the market, and are technically easier to insert, but importantly allow the surgeon and the patient to tailor the treatment to the needs of the patient.

Recent treatments for impotence The last 40 years have seen a rise in the available options to treat impotence, although interest in the condition has really only grown in the last 10 years. Geddings Osbon, a Pentecostal preacher, who had founded a successful tyre re‐treading business, fashioned a prototype vacuum device from tyre pumps in the mid 1970s. He hooked a bicycle pump to a truck tyre valve, reversed the cylinder to create a negative pressure and applied this to his penis, resulting in an erection. In 1982, Osbon received FDA approval to market the product as the ErecAid®, and in 1984, Osbon Medical Systems (Augusta, GA) was founded with his son Julian [64]. Ronald Virag, a French vascular surgeon, discovered intracavernosal therapy almost by accident. In 1980, he accidentally injected papaverine and produced an erection in his patient [65]. Meanwhile, Giles Brindley, a 57‐year‐old Englishman, independently of Virag, described an erection after the intrapenile administration of phentolamine [66]. Brindley actually went a step further; in 1983, at the AUA conference in Las Vegas, he stepped in front of the podium whilst presenting his work, and demonstrated to the audience his own erection from self‐injection [67]. This was how the idea of intracavernosal therapy started. Many drugs and their combinations have since been identified, and are used for injection therapy. The first anti‐impotence drug, alprostadil, was marketed in 1995 and is available as a local injection or an intraurethral pellet. The latter method of delivery was discovered after it was noted that drugs could be absorbed into the cavernosal bodies through the walls of the urethra [68, 69]. More recently oral therapies for the treatment of impotence have been marketed, starting with the accidental discovery of sildenafil citrate (Viagra). In 1991, researchers discovered that chemical compounds belonging to the pyrazolopyrimidinone class were useful for treating cardiac conditions such as angina. In 1994, whilst trials for this were underway (with little success) it was noted that the drug also increased blood flow to the penis and therefore increased erections. Subsequently, in 1998, the FDA gave approval for sildenafil citrate as the first oral anti‐impotence drug [70]. With the latest addition, apomorphine (Uprima), there is now a race to produce a pill with a faster onset of erection, fewer side‐effects, available to all patients and with no restriction on the frequency of use.

Conclusion A recent study estimated that 152 million men worldwide experience some degree of impotence. In addition, based on population projections, it is likely that the prevalence of the condition will more than double over the next 25 years [71]. In the world's seven major pharmaceutical markets (USA, France, Germany, Italy, Spain, UK and Japan), the forecast sales of therapies to treat impotence is expected to quadruple, from $880 million to almost $4 billion between 1998 and 2008 [72]. There is no doubt that this is a common condition that can be debilitating. The associated anxiety, depression and feelings of low self‐esteem can compound the problem [73]. The history of impotence has taught us that until only a few years ago, this condition was still considered to be of psychological or supernatural origin. Today, the development of numerous treatments has allowed the social stigma to subside and both the patient and the physician some choice in how to manage the condition.

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