The Loving Pie by Ralph and Barbara Alterowitz

This article was originally published in the Us TOO Hotsheet in May and June of 2005. –

[Editor’s Note: This is the first of two articles on reviving intimacy after prostate cancer treatment. The second article will talk about the many treatments available for obtaining erections, how to use them, and their side effects.]

Intimacy and sexual pleasure is known to be essential to good physical and mental well being; it may even lengthen life. Unfortunately, many couples abandon intimacy after prostate cancer treatment, unaware that their intimacy can not only be revived but possibly made better than before. Often all a couple needs is a vision of what intimacy could and should be for them and how to go about regaining it.

The devastation wreaked on many couple’s love life by prostate cancer is shown in the following comments from participants in an on-line forum. Women’s comments: “Since his prostate cancer treatment, we have gradually settled back into pretty much a sexless marriage.

We love each other. So, what has happened?”“His libido seems to be totally gone. He has ED [erectile dysfunction] and doesn’t seem to care. I had no clue this would happen when he was first diagnosed. Now I don’t sleep and sometimes I think I can’t live through this. But another day goes by and I do. I still can’t believe this has happened to us.”

“I’m not ready for celibacy. I am having a major problem coping with isolation, loneliness, and living with aguy who seems to have forgotten I am here.” Men’s comments:

“I’m 51 years old…and I haven’t touched my wife in I don’t know how long. I don’t feel like a man anymore.” “Do I think about it? Most of the time, I try to keep my mind busy so that I don’t think about it. I try to focus on other things. But there are moments when the thoughts slip through. I hear a song about making love… Orsee a scene in a movie…. and am reminded that that is something I will never have again.”

These couples all fell into hopelessness because they think erectile dysfunction (ED) means the end of intimacy.But other couples know that ED can open the door to a revived love life because it forces us to reinvent our sex-ual relationships. Some key insights from the happier side of the ED community include:

It is possible to make love after prostate cancer treatment, with or without mechanical aids or medications.

It is possible to have fabulous erection-free sex. That’s because arousal, erection, and orgasm use different“wiring.” Both men and women can experience sexual pleasure and orgasm without penetration.If the goal is to express love for one another, there are wonderful and creative ways to be intimate. And intimacy

means staying connected as a couple.Both partners share the responsibility to talk about their sexual wants and needs, and to try new ways to giveeach other pleasure. But one partner has to have the courage to start the conversation.

What Is “The Loving Pie?”

In a good long-term relationship, love is the emotional underpinning for intimacy. Sex is really a combination ofarousal, erection, and orgasm. Arousal is necessary for sex but there may be no erection or the man or woman may not have an orgasm. Many people think of arousal and erection as one because in younger men they seemedto happen simultaneously. But as men get older there is a delay between arousal and erection, and erection some-times does not occur at all.

Certainly, if the man is distracted by something he and his partner have been arguing about, he is not likely to

get aroused, and therefore he will not have an erection.We like to use the metaphor of a pie to describe a loving relationship. (the scientific or technically orientedmight want to think of it as an integrated system). Good sex is only achieved if all the parts are brought together.

The pie’s crust, the foundation for the entire relationship, represents the quality of the relationship and is expressed in the way the partners behave toward one another. If the crust falls apart, there is no pie.The filling is a combination of ingredients that give the loving pie its unique flavor. The three primary ingredi-ents are:

  • communication
  • an agreement by the couple to get to know each other again
  • an atmosphere or general feeling of love that enables the couple to have sensual sex.

Mechanical aids or medications are toppings, because they may be used to enhance a sexual experience withinthe context of the filling. But they are not essential for good loving. This is a surprise to people who are not aware they can have sex without erections. But erection-free sex can be a wonderful experience for both partners. Also, having sex without an erection changes the sexual experience.

Let’s take a closer look at making the loving pie. The Crust Making the loving pie crust means getting out of a “rut” relationship—one that is routine, unappreciated, andtired—and developing a “crest” relationship—one that has creativity, respect, excitement, sensitivity, and to-getherness. Too often, a marriage becomes a roommate relationship, which does not foster arousal. It’s important to revivethe spirit that brought a couple together in the first place.

The Filling

Communication is the key to the loving pie filling, yet many couples do not understand what it means in every-day life. Communication is the ability of the partners to talk with each other about all aspects of their lives, espe-cially the sensitive topic of sex. A couple cannot argue or be angry with each other much of the time and expectto get into the mood for good sex, or even plain sex. A relationship without communication is one where the major connection between the partners is missing.

Impotence is not a man’s problem; it is a couple’s problem. Very often a man’s impotence becomes the 600-pound gorilla in the relationship, leading to a “conspiracy of silence” where neither partner wants to begin theprocess of dealing with it. As one man said “I try to think of other things and not say anything that will bring upsex.” The partners must talk about their feelings about impotence, and about sexuality in general, if they want todevelop the loving pie. Sexual likes and dislikes must also be expressed.

Getting reacquainted with each other is necessary because cancer and the treatment consequence of impotencechange a couple’s thinking about many aspects of life, not just loving. Getting reaquainted involves learningabout one another again; that means taking time to touch one another, and to explore each other’s personalityand each other’s anatomy.

Couples can’t assume they know each other’s bodies. People change as they age and the consequences of pros-tate cancer treatment often change where a man feels the most pleasure. So it’s good to have touch sessions andtell each other where the pleasure is greatest.

Finally, to get on the road to sensual sex, it helps to start to think love, not sex. Getting in the mood for sex means thinking about the pleasures of kissing, touching sensitive areas, and creating a sensual mood. Each ses-sion of love making is a chance to learn and try different things, positions and techniques. Focusing on what iscommonly called foreplay can reduce the anxiety about erection and intercourse, and heighten the pleasure. Sometimes people lose sight of the fact that great sensual sex is a whole-body experience, that involves all yoursenses and your mind and soul.

The Toppings

Toppings can change the taste of a pie. They can enhance the basic flavor and vary the taste of the same pie. Thesame is true for the toppings of the loving pie – the aids and medications. Toppings can help men obtain or im-prove the rigidity of an erection. These can be pills such as Viagra, Levitra, and Cialis, or injections, or devicessuch as vacuum pumps or splints, or implants.

One reason so much attention must be given to the crust and the filling is that medications generally increaseerectile quality only when there is arousal. This means the emotion of love has to be in place before medicationcan create the physical condition for sex.

This is one of the reasons why we say that using a topping as a filling doesn’t work. If a couple just wants sex,but doesn’t have the love, taking a pill won’t help. It’s the same as the man who said that he took a Viagra andread the newspaper for an hour and nothing happened. And using a mechanical aid might provide the ability tohave wham-bam sex, but it probably won’t be truly pleasurable for both partners.

On the other hand, if an aid or medication topping is combined with the “crust” of a good relationship and a deli-cious “filling” of good communicating, understanding each other’s personality and bodies, and sensual enjoy-ment, the loving pie is absolutely delicious.

As with any other treat you have given yourselves over your life together, a loving pie takes time to prepareproperly, so savor it.

Ralph and Barbara Alterowitz, husband and wife, are popular speakers, intimacy counselors and co-authors of Intimacy with Im-potence: The Couple’s Guide to Better Sex After Prostate Disease, (2004, Da Capo Press). The book is available through www. with proceeds furthering education efforts on intimacy after cancer, at bookstores, and will be part of Us TOO’s Circles of Love Care Kit, an education and support program for companions and family members of prostate cancer patients. Us TOO Circles of Love Care Kits will be available Father’s Day, June 2005 at or 1-800-808-7866. They are prostate cancer activists and members of the American Association of Sex Educators, Counselors, and Therapists.


By Barbara and Ralph Alterowitz

[Editor’s Note: This is the second of two articles on reviving intimacy after prostate cancer treatment. The first article appeared in the May 2005 Us TOO HotSheet and dealt with laying the basis for good loving. This article talks about the many therapies available for treating erectile dysfunction, how to use them, and their side effects].

To briefly review the loving-pie metaphor, the crust is the quality of the relationship and how the partners interact with each other, and the filling ingredients are primarily communication, an agreement to get to know each other all over again, and an atmosphere of love. The toppings are things that can enhance the sexual experience, but are not essential for good loving.

In the context of The Loving Pie, we frame the idea of using therapies and medications as toppings. Toppings would be things a man can do or take such as one of the pills that might help him attain or maintain an erection for a specific love-making event.

Before dealing with available therapies to help men get or improve an erection, we need to talk about the degrees and causes of erectile dysfunction. Many men are not totally impotent but they may not be able to get an erection sufficient for penetration. Researchers grade the degree of penile rigidity on a scale of 1-10. In that light, a man who cannot get the same level of rigidity he remembers from his younger years would have some erectile dysfunction, but he would not be called impotent.

This brings up the first thing we need to be clear on. Aging is probably the major cause of erectile dysfunction. As the years go by, hardening of the arteries and changes in the nervous system prevent men from getting the erections they once knew. Other things also affect and change a man’s ability to get an erection.

Lifestyle choices have a profound effect on overall health including erectile capability. These include diet, activity level, and factors such as smoking, drinking and use of certain prescription, over-the-counter, or even street drugs. All of these affect the body’s capability to get aroused and to pump blood into the penis, allowing for a sustained erection. Fat in the diet clogs arteries in the penis as well as those that lead to the heart (and indeed in the entire body).

In addition, surgery, radiation, injuries, and physical or mental illness may cause problems with the blood circulation and may damage nerves. Erectile function is also influenced by transient emotions such as feelings of guilt or anxiety about having an erection. Impaired blood circulation and/or nerve damage causes a man to need more time to get an erection and often more direct stimulation.

For prostate cancer patients, treatment may also cause or worsen erectile dysfunction:

  1. After surgery, even with nerve-sparing techniques, a man’s remaining erectile ability may take two years or even longer to recover. Nerves are damaged or at least manhandled during surgery, so even if potency returns, it is often less than before.
  2. Radiation of all types will reduce a man’s erectile capability, but at a slower pace than surgery. However, after four years, the percentage of men with erectile difficulties is the same for both surgery and radiation.

Penile Rehabilitation

An important therapy to aid in recovering erectile capability that all men should consider in consultation with their health care professional is what is now called penile rehabilitation therapy. To put it simply, this therapy is based on using medication or a device almost daily to produce erections, not for the purpose of intercourse but rather to get blood flowing into the penis. Vacuum pumps, injections, or pills may be all prescribed for this purpose. As is obvious, some means are less expensive that others.

For the newly diagnosed prostate cancer patient, it is important to be aware that a nerve-sparing procedure is not always an option. The patient may want to explore with his doctor whether neural grafting might be feasible in such a case. This procedure involves taking a nerve from the ankle or the lower part of the abdomen and filling in the neural gap near the prostate gland, where nerves have been cut. This must be done at the same time as the prostatectomy.


Ideally, it would be nice to have one therapy that everyone can use to achieve an erection. We would all like a single therapy that:

  • is effective,
  • works when it’s needed,
  • is not toxic and has no side effects,
  • is easy to use such as pills or cream, and
    • is inexpensive. Given that such a wonderful all-purpose medication does not exist, let’s look at the therapies and medications that are available. These are just highlights and do not provide the comprehensive medical information a man needs to make an informed judgment. Any approach a man wants to use should be discussed with his doctor or other health care professional.
    • In the past five years many commercial therapies—medications and aids—have become available to swell the arsenal of options to help men get an erection. The list consists of: •oral medications
  • injectible medications
  • transurethral drug therapy
  • a broad range of devices that include vacuum erection devices (VED), constriction rings, penile splints, and even vibrators. These are external devices for aiding a man in obtaining an erection at the time it is needed.
  • Penile implants are internal devices that are surgically implanted for long term use. Before using any aid, there are a number of things to think about:
  • Try a medication or aid only if both partners want to. You need to know how each of you feels about using them.
  • Each aid has its own advantages, drawbacks, and side effects.
  • Medications may not work equally well all the time. A product that works one time may not work as well, or at all, the next time or later on. And one that has not worked one time may work another time. Some work better with longer-term use. None are guaranteed to work, and many work only on a certain percentage of patients.
  • Many of the drugs have considerable side effects.
  • The drugs and devices aid in obtaining erections, not orgasms. On the other hand, a man can have an orgasm without an erection. Conservative medical guidance is to start with a low dosage and work your way up as necessary. Follow your physician’s advice concerning drugs and dosages. Sometimes a physician may start a patient with a high dosage to increase the probability that the patient can experience some success.
Oral medications

A pill fits the primary feature that a man generally looks for in erection medication: it should work quickly. A man is likely to think in terms of a popular ad for one pill – “will you be ready?” When he needs it, he wants it to work almost immediately without any fuss or bother.

Three pills are currently available: Cialis®, Levitra®, and Viagra®. There are differences between the three that refer to how quickly they act, how they should be used, dietary restrictions and side effects.

It is mandatory that the man be aroused before any of the pills will work. Levitra and Cialis promotions say that a man can achieve an erection about 20 minutes after being taken. Soon after their announcements, Pfizer announced that Viagra, the first pill available, can also work in about 20 minutes to a half-hour. Previously, Pfizer’s instructed users to observe the dietary restrictions, i.e., it should be taken two hours after an, ideally, low fat meal. Then the man must wait 20 minutes to an hour before he would have the capability to have an erection if he is aroused. Levitra and Cialis, do not have the same dietary and time restrictions.

A cautionary note is that all medications must be taken under medical guidance. A physician must determine the appropriate dose consistent with the patient’s medical history. Unfortunately, although these are prescription products, many knockoffs are offered over the internet. While the prices may seem attractive, the quality of production, the content of the pills cannot be verified, and the consequences of taking these pills are unknown. Moreover, using these pills without medical supervision puts patients at great risk.

Another point worth noting concerns using pill cutters to obtain more than one dose from a pill. It may seem logical to split a large-dose pill in half. The drawback is that the active ingredient may not be evenly distributedthroughout the pill, so the dosage in each part is different Also, breaking the coating may alter the effectivenessor produce side effects if the drug was designed to be absorbed in a certain place in the digestive system.

Men should be aware that these drugs do not increase desire. All they do is help a man who already is aroused achieve an erection – if they work for that man. And for many men, they may not work at all.


Injections essentially always work and yield quick results, but it means taking time for an injection into thepenis. The most well-known, Caverject®, also has several competitors, Edex® and Invicorp®. Many men feelqueasy inserting a needle into their penis. The actual effect is a slight pin prick. The quick insertion in the correctposition provides a prompt erection. Many men preferred the injection even after Viagra became available because of the latter’s food and time restrictions. One group of injection medications, called blends, has the advantage that a doctor can tailor them according to a patients needs and to minimize side effects.

Intraurethral Medication

MUSE requires that a man insert a very thin syringe into the penis to deposit a tiny pellet or suppository deepinto the urethra. As with many medications, the man’s responsiveness in terms of erectile capability varies. Themanufacturer, Vivus, introduced a ring, a clamp-type device, Actis®, that men can use to retain the erection.This ring is similar to the constriction rings available with vacuum erection devices.


The best known of the external devices are vacuum erection devices, known interchangeably as VEDs orpumps. These are mechanical appliances to aid men in obtaining an erection. The upsides are the ability to obtain an erection fairly easily, reliably, and without medication side effects. However, some men and partners areturned off by the need to stop and use the pump. Some manufacturers suggest that both partners participate inusing the device so that its use becomes part of lovemaking.

For most men, using the pump will also require the use of a constriction ring to keep the blood in the penisand thereby retain the erection.

VEDs are also often prescribed by physicians as the preferred means for penile rehabilitation mentioned previously.Although there may be a higher initial cost than injections or oral medication, over a long period, it may cost less.

A penile splint may be used for rigidity to enable penetration. However, it must be used with care.

Penile implants are for men desiring long term solutions for obtaining erections almost at will. They must beimplanted surgically. Some implant procedures are performed as outpatient surgery, and all surgery carries risks suchas post-operative infection, pain, and device malfunction. These risks have been reduced in recent years. Current devices are quite reliable and can last anywhere from eight to twenty years. Patients report high levels of satisfaction. THERAPIES IN COMBINATION AND DEVELOPMENT

Even with all the recent advances, the current therapies are not ideal and do not work for some men. Sometherapies may be used in combination such as a clinician prescribing a pill to be used with a vacuum device. This increases the success rate for some men, but must only be done in consultation with a physician.

Clinical studies are in progress exploring the value of other approaches. A topical, gel-type product is still being studied in the U.S. but is already in use in Asia. New oral therapies are in clinical studies that may work on the nervous system and on muscles. Pfizer’s early breakthrough with Viagra, and the demand for all pills, seemsto have spurred companies to unlock the research gates to help men improve their erectile quality.

There are many “toppings,” or means, to aid men in obtaining an erection. But the underlying satisfaction insexual intimacy must be the relationship between the partners and the erection is for a little extra spice.

Think Love! Make Love!

Ralph and Barbara Alterowitz, husband and wife, are popular speakers, intimacy counselors and co-authors of Intimacy with Impotence:The Couple’s Guide to Better Sex After Prostate Disease, (2004, Da Capo Press). The book is available through with proceeds furthering education efforts on intimacy after cancer, at bookstores, and is part of Us TOO’s Circles of Love Care Kit, and education and support program for companions and family members of prostate cancer patients. Us TOO Circles of Love Care Kits are available at or 1-800-808-7866 . Barbara and Ralph are prostate cancer activists and members of the American Associa-tion of Sex Educators, Counselors, and Therapists. They can be reached at

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