It is a disorder characterized by an inability of an individual to urinate in front of other people or in situations where they think other persons are present.
The condition is also referred to by various other names, such as:
- Shy Bladder Syndrome, or simply Shy Bladder
- Shy Kidneys
- Bashful Bladder
- Pee Shyness
- Toilet Phobia
- Avoidant Paruresis
- Shy Cock
- Restroom Phobia
- Fear of the Restroom
- Fear of Toilets
- Psychological Urinary Retention
People who suffer from this disease are referred to as Paruretics.
The name of the disorder was coined by Degenhart and Williams in the year 1954 and was used in their paper “Paruresis: a survey of a disorder of micturition” in the Journal of General Psychology 51:19-29.
7% of the general population or around 17 million US inhabitants tend to suffer from the disease. Approximately 51 million Europeans and 3.25 million Canadians have been reported suffer from this social anxiety disorder.
As aforesaid, patients of this disorder usually suffer from a fear or shyness to urinate in the presence of strangers or people who are unknown to them. The condition is much more frequent when strangers are present in loos or restrooms and peeing next to them. Those with mild forms of the condition are unable to pee in some surroundings but able in others. Those with more severe forms of the disorder can only urinate at home.
This is usually a progressive problem with fear worsening and generalizing over a period of time to more locations.
The disease can arise at any time of life and can persist for any duration. Some individuals may have a temporary episode of the disease, such as while being told to provide a urinary sample as a part of some diagnostic test, while some others suffer from the disorder for as long as they live.
People often find the condition coming and going throughout their life, based on factors like the general levels of stress or anxiety for the rest of their lives.
In many people regularly suffering from Paruresis, the condition usually arises during the teenage years.
This disorder is likely to have more than one causes. Some patients of this disease may have had overly critical parents or guardians in childhood or had probably been victims of bullying at a very young age.
The typical causes for this disease include:
- Unresolved psychological conflicts
- Underlying stress or anxiety
- Anticipation of occurrence of Paruresis
- Worrying about previous experiences of the condition
- Fear of being judged (also referred to as social phobia or social anxiety)
- Performance Anxiety, such as fear of patients about whether they would be able to urinate in a new toilet
Growing up in an environment where urination and/or toilets were seen as ‘dirty’, or where ‘toilet issues’ were considered to be shameful can also give rise to Paruresis. Patients may feel the urge for urination actively suppressed or suffer from guilt due to such an upbringing.
The three main trigger factors for the disease are:
Presence of strangers in restrooms
The disorder is found to be more common when strangers, and not relatives or friends, are present in a restroom thus increasing the shyness and fear of patients to urinate before such people.
The proximity referred to in this case is both physical and psychological. The physical proximity of others, such as their relative nearness of strangers to affected individuals, can have a negative impact on the desire to urinate for sufferers. The psychological proximity includes the need for privacy for patients, who may have a feeling that they are not alone even in deserted restrooms/toilets.
Temporary psychological states
Temporary psychological states of patients, such as anxiety, fear or anger can also interfere with urination.
Paruresis Risk Factors
The risk factors for this disorder include:
Being abused in childhood
Those being bullied when young can be susceptible to this disease. People with repressed upbringing in childhood can also be prone to the disorder.
Previous traumatic experiences
Inability to urinate in certain past situations, such as while providing samples for a diagnostic test, can cause the development of the condition.
The diagnosis of this disease is based on the symptoms reported by sufferers. Patients of acute cases can waste a lot of time in waiting for all others to leave a toilet before they can urinate. They might also completely avoid urinating in public toilets.
The disorder is generally self-detected when any of the three primary triggers for the condition are present and the disorder is chronic in nature.
Inability to urinate may also arise due to conditions such as Prostatitis. Physicians can carry out a series of exams to ensure that there is nothing wrong with the urinary tract of sufferers. They may ask patients whether they can comfortably urinate at home. If sufferers confirm that they can, the condition can be confirmed as Paruresis. Doctors may prescribe the short-term usage of medications like antidepressants or tranquillizers. However, these drugs cannot cure the disease and only serve to reduce associated symptoms of anxiety.
In acute cases, physicians may recommend patients to learn self-catheterisation. A catheter is a slender tubular structure that is inserted into the bladder up through the urethra to drain urine.
Paruresis Differential Diagnosis
The differential diagnosis of Paruresis includes isolating its symptoms from those of similar signs of other conditions like Prostatitis.
The disorder was once dismissed as a symptom of some mental problem, such as anxiety. However, there has been a growing recognition of the disease by the National Health Service (NHS) of the UK and the government. The American Urological Association also recognizes it now and has included it in their online directory of disorders. It is classified as a type of social phobia in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) in the United States and is known as a form of chronic social anxiety – which is being disputed by some medical professionals.
The most well-documented current curative options are based on cognitive-behavioral therapy, which aims at reorganizing the abnormal emotional problems arising due to factors that trigger Paruresis. This can be performed in a support-group, in self-help scenarios or through psychotherapy by a psychiatrist or psychologist.
Therapy involves three isolated, although associated, components:
It aims to modify the unusual ideas and thoughts around the object of anxiety. Some patients report that they have a sensation of people looking at them when they urinate in public toilets.
This involves a stepwise desensitization of sufferers by slowly exposing them to the situation that causes fear in their minds. This is known as “Exposure Therapy.” The process aims to reassure the subconscious of sufferers through a series of small steps that they are “safe” to urinate in public toilets or restrooms and there is nothing “shameful” in the act. This is a type of “learning” to urinate again in a social surrounding. According to the International Paruresis Association (IPA), around 80% of patients who receive this type of treatment show improvement. Sufferers are taught to gradually use restrooms in increasingly difficult situations; it is generally carried out under the supervision of trained behavioral therapists.
It involves teaching patients a system of exercises that bring about both psychological and physical relaxations, such as sphincter relation exercises.
Paruresis – Alternative Treatment
Saw Palmetto is a possible alternative curative option for this condition. It is used to cure urinary problems in men suffering from BPH, an enlarged prostate gland. This enlargement of prostate leads to its inflammation and obstruction of the urethra. It results in a variety of problems, such as:
- Reduced urine flow
- Painful urination
- Dribbling after urination
- More frequent nighttime urination
- Difficulty starting or stopping the flow
A typical dose of Saw Palmetto is 320 mg per day of its standardized extract. However, patients may take as long as up to 4 weeks to show any benefits.
Paruresis and Medications
The disorder can be cured with the aid of some types of medications. SSRI drugs such as Zoloft, Paxil and Prozac can be useful. Benzodiazepines such as Valium, Klonopin or Xanax can be used while in public or before the drug test to relax the muscles and bring down the anxiety level in patients enough to make them able to produce a urinary sample.
Many sufferers of this disorder never seek medical assistance or treatment. They never even have a discussion about the problem with anyone. In such cases, the condition often goes unresolved and continues life-long. However, anecdotal evidence suggests that those who seek medical assistance have a good rate of success at overcoming the sensations of anxiety and fear over a period of time. The time for recovery can be a year or more.
The disorder, if left untreated, can have a damaging impact on the mental health of sufferers. They can have serious difficulties in workplace and maintaining jobs. Those with acute cases of the condition may find it difficult to go out or have long distance-journeys. Withholding urine for long periods can also affect the kidneys and cause embarrassment when patients can no longer hold their urine. Patients may also suffer from psychological difficulties such as anxiety and depression.
As of now, there is no way that is known to prevent the development of this disease. According to anecdotal evidence, the condition does not arise until a person is around the pubertal age. Doctors usually recommend children to start urinating in public restrooms from an early age to prevent the development of this disorder.
If you, or any of your family members or friends, are having an embarrassment about urinating in public lavatories, seek psychological help and counseling on an immediate basis. As aforesaid, long-term episodes of this condition can affect the quality of your life and also severely affect your mental health. Naturally, it makes sense to opt for medical help as early as possible.