Although the observations of Masters and Johnson [2, 3] gave a more documented and descriptive nature of sexual physiology it was followed soon by the realization that simple treatment behavioral modification did not work in all individuals because of the overlapping secondary individual and partner interactive processes playing a “resistant” to cure so therefore a new paradigm for therapy was developed that combined behavioral modification of sexual symptoms of classic therapy with brief, active psychodynamically oriented management of the patient’s resistance [4]. A third seminal development in understanding human sexuality from a monistic process to the development of a triphasic paradigm was proposed by Dr. Kaplan in the late 1970s [5, 6]. Even this triphasic stepwise nature of sexual reactivity has been recently modified (see below). This triphasic nature of the sexual response moved the evaluation and treatment from a simple clinical entity to more complex interactions in the one individual to several interacting components but also to a series of interactions between the partner’s sexual response as well. An example of the inadequacy of treating a man for ED without recognizing the patient’s main problem may be hypoactive sexual desire, which if not addressed as well, would lead to therapeutic failure to treat the impotence [7]. Michael Perelmann about 7 years ago nicely summarized a new integrative approach to the management of sexual dysfunction [8].

At about the same time that this new focus on the diagnosis and therapy was occurring in the sexual therapist realm two studies emanated out of Europe focusing on recognition of possible vascular restoration occurring with pelvic vascular surgery for impotence [9]. The other publication was the elegant radiological evaluation of the intracoporeal and pelvic vasculature via specialized arteriography [10]. These caught the attention of two key clinical investigators at that time, Adrian Zorgniotti of New York City and Gorm Wagner of Denmark, who also had performed some elegant observational studies of physiological changes in the female genitalia and the male corpus cavernosum, to team as leaders in preparing a meeting in New York City in the fall of 1978 to discuss some of this new cutting edge treatment and evaluation of impotence which sequentially became the biennial meeting for at first impotence, then all of male sexual dysfunction to eventually sexual dysfunction in men and women under the current organization , the International Society for Sexual Medicine [11]. More detailed historical data regarding Dr. Zorgniotti can be found in Dr. Lizza’s 2005 article [12]. At the 1978 meeting in New York City 188 revascularization procedures, mostly inferior epigastric artery to the corpus cavernosum (Michal I) were presented from 7 international sites with as high as 77% positive functional result [11]. The sophistication of presentations led to plans to address more science associated with penile erection and treatment of impotence at a second meeting in Monaco in 2 years in 1980. See Ref. [10] and the book that also was published on data from this initial 1978 meeting [11, 13]. By the time of the meeting in Monaco results of revascularization of the corpora cavernosa for impotence was reported from nine new centers in addition to Michal’s group, most now using the Michal II, inferior epigastric artery anastomosis to the dorsal artery of the penis [11]. A unique revascularization procedure using the inferior epigastric artery to the deep artery of the corpora were also reported in a few cases from Latin America and the United States but long term follow up of these procedures and later reports of similar surgeries never appeared again. This revascularization group also included the first report of the Virag Technique of deep dorsal vein arterialization for vascular treatment of erectile dysfunction [11].

It is beyond the scope of this brief history of evolving sexual medicine to continue where this initial enthusiasm for penile revascularization treatment led but long term results were certainly mixed with major occlusion eventually for the revascularization arteries, probably due to some of the need for physiological runoff for successful revascularization and the non-physiologic connections such as to deep dorsa vein without runoff established to the corpora cavernosa itself or direct connection to the corpus cavernosa. Today only specific traumatic damaged pelvic internal pudendal arteries or the branches to the corpora verified by specific sophisticated pelvic arteriography (with ability to use the inferior epigastric artery as a donor artery to anastomotic vessels beyond the specific damage site such as dorsal arteries with definite branches to the corpus cavernosal deep artery serving as run-off vessels) should be the patient of choice for revascularization procedures. These are usually young patients with specific pelvic trauma. Certainly arterial damage is more generally small vessel disease in the corpora cavernosa itself now proved by more anatomical and physiological studies particularly in those patients with generalized vascular disease such as arteriosclerosis and microvascular injury in association with such diseases as diabetes mellitus (DM) . This medical approach tended to blossom with overenthusiastic surgeons before some of the needed anatomical and physiological sciences of the corpus cavernosa were well understood.

Before the “new focus” on understanding the nature of the tissue of the penis erectile tissue and the 1978 awakening of alternative vascular repair for this disorder, a group of surgeons from various regions of the world had gradually developed the replacement of the physiologic process of erection with penile prostheses. This progressed from several types of artificial “os penis “devices being placed in the penis, but not into the corpora cavernosa itself, to intracavernous rigid and semirigid devices placement to various hydraulic intracavernosal prostheses. Semirigid , and two or three piece devices persevered to remain a major therapeutic success story of the treatment of ED. The reader of this historical piece is encouraged to read previous selected publications which well spell out this history of prosthetics for the treatment of ED [14]. One persistent characteristic of this modality is the constant nature of the surgeon and engineer to improve these devices to lessen mechanical wear, to develop infection resistant materials to aid in that devastating end point prevention, to improve the surgical techniques for placement of the devices, and to develop sophisticated salvage procedures when failure occurs. Key early pioneers in this field include Brantley Scott, William Furlow, Steve Wilson, Carl Montague, and Gerald Timms from Minnesota. At the second international meeting on impotence in Monaco in 1980, this area was highlighted in the program. A supplement to the Journal of Sexual Medicine in November, 2015 presents a review of historical papers with commentary in penile implant surgery [15]. Also another history review was published in sexual medicine reviews [16].

By the time of the 1982 third meeting on penile revascularization in Copenhagen, and certainly by the fourth meeting in Paris 1984, a new dominant therapy for ED was developing rapidly, injection of vasoactive agents into the corpus cavernosum [17, 18]. Another rich historic narrative on injection therapy from its beginnings can be found in a chapter from a Wagner and Kaplan 1993 publication [19]. Giles Brindley and Ronald Virag were the early pioneers in this field in 1982 and 1983 [17]. At first Virag proposed intracavernous injection therapy as an office procedure but auto-injection at home was proposed by Zorgniotti and LeFleur in a publication in 1985 [20]. At the fifth international meeting in Prague in 1986 the introduction of prostaglandin E-1 as the newest injection agent was made in laboratory and patient studies were presented from Singapore, Japan, and Vienna, Austria [17, 18]. A 3 year follow/up of 69 patients using self-injection of prostaglandin E1 was reported from Finland in 1999 [21]. In 1996 intraurethral prostaglandin E1 was approved but its efficacy was less than injection therapy [22].

One cannot discuss the history of injection therapy without citing a most seminal review article in the field by Junemann and Alken in 1989 [23]. The major agents used in diagnostic studies and therapy are two- or three-agent combinations using papaverine, phentolamine, or PGE-1 or using one of two FDA-approved PGE-1 agents alone [18]. Although a highly successful therapy for the treatment the invasive nature of the treatment is not well accepted by all patients and the long term dropout is still relative high. To demonstrate the rapid spread of this treatment for ED, at the 1984 meeting in Paris there were only five presentations dealing with intracavernous treatment for ED and in the subsequent 1986 and 1988 meetings there were over 45 presentations on the same subject [17]. Pharmacologic agent injection also became a major part of some of the diagnostic procedure as discussed below. The use of injection therapy for diagnosis, evaluation, and treatment of ED has been recently reviewed [24].

By the time of the third and fourth meetings of the international group in Copenhagen in 1982 and Paris in 1984 some therapeutic and diagnostic studies stressing the veno-occlusive mechanism of erection were being addressed. Our group from Tulane University in New Orleans reported at the fourth international meeting in Paris in 1984 a dynamic corpus cavernosography [25]. We, in the introduction to that paper, discussed some of the early venous surgery for ED by Lowsley as early as 1953 and we presented some of our early vein surgery patients. We also credited early modern pioneers of venous surgery in the modern era, Ebbehof, Wagner, and Virag. In 1990 we presented an article on venous ligation surgery for venous leak in which we reviewed the earlier contributors and the then known results from around the world [26]. However long term results of this type of surgery were not sustained overtime mainly because it became apparent that veno-occlusive disorders were mostly the result of fibrotic changes in the sinuses of the corpora cavernosa and addressing the external veins would not change the lack of veno-occlusion which was dependent on total relaxation of the corpora sinuses . This type of surgery is now reserved for rare congenital venous defects in the wall of the corpora cavernosa and some rare cases of trauma or iatrogenic damage to the tunica albuginea.