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in the 1920s and 1930s. Tribulus had been used as traditional medicine to treat sexual dysfunction and male infertility in Europe and Asia for many decades before improvement in scientific extraction techniques allowed identification of its active ingredient, protodioscin. There are two forms of impotence: primary and secondary. Impotence was once solely defined as the inability to achieve an erection. Now it is also defined as the inability to maintain an erection or ejaculate. Stimulation of the penile shaft by the nervous system leads to the secretion of nitric oxide (NO), which causes the relaxation of smooth muscles of corpora cavernosa (the main erectile tissue of penis), and subsequently penile erection. Other studies have suggested that Tribulus also acts by increasing the level of dehydroepiandrosterone (DHEA), a naturally occurring substance in the body believed to be important for a healthy sex drive. When pharmacological methods fail, a purpose-designed external vacuum pump can be used to attain erection, with a separate compression ring fitted to the penis to maintain it. If the stamp is no longer in place by morning, it means that a nocturnal erection occurred. in the 1920s and 1930s. Secondary impotence, defined as the loss of erectile function after a period of normal function, is more common. Impotence can be treated — sometimes even without drugs. Penile erection is managed by two mechanisms: the reflex erection, which is achieved by directly touching the penile shaft, and the psychogenic erection, which is achieved by erotic or emotional stimuli. Although they are often dismissed as ineffective solutions to impotence, more and more clinical research studies have found that herbs can help impotent men. Other studies have suggested that Tribulus also acts by increasing the level of dehydroepiandrosterone (DHEA), a naturally occurring substance in the body believed to be important for a healthy sex drive. Furthermore, studies have shown that lack of testosterone leads to a range of other sexual performance problems, including premature ejaculation and low sex drive. It is estimated that about 10% to 20% of impotence cases are the direct result of various psychological factors, such as low self-esteem, depression, and — especially — stress and anxiety (general and performance anxieties). The ring remains on the penis until intercourse is finished.

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