Problems Urinating in Public (Paruresis)
Do you or someone you know experience difficulty urinating in the presence of others? If so, the following article may provide you with some insight into this social anxiety disorder.
What is paruresis?
Paruresis, often referred to as bashful or "shy bladder" syndrome, is a phobia that involves fear and avoidance of using public bathrooms and an irregular idiopathic form of urinary retention (when you are unable "to go"). The key point to note is that this form of urinary retention is not caused by a physical blockage in the body. People who suffer from paruresis have trouble urinating in the presence of others. More accurately, paruresis is the fear of not being able to urinate without some or complete privacy, depending on the severity of the symptoms. This disorder can interfere in a person's quality of life in a number of areas. Paruretics face difficulties ranging from work problems (when they have to submit a urine analysis for drug testing) to traveling on long plane rides to every day social situations.
What causes paruresis?
There are many questions still to be answered about the cause of paruresis. This condition can afflict a toddler in preschool, a child in early or late adolescence, or even a person in mid to late adulthood. While some paruretics cannot point to any specific triggering incident, others believe their ailment was triggered by a traumatic incident that happened prior to or during adolescence including embarrassment by a parent, teasing by classmates or siblings, harassment in public bathrooms or sexual abuse. Although many children experience such incidents (e.g. being teased by peers while trying to use a public toilet or urinal), not everyone develops paruresis. Note that it is pathophysiological in nature, and recent research in the field of neurology shows that there may be somatic as well as psychiatric components to the problem.
How common is paruresis?
While there is no way for certain to know how many people suffer from paruresis, surveys done over the last several decades indicate that the numbers could range from less than one percent to more than 25 percent of Americans. The 1994 National Comorbidity Survey indicated that 6.6 percent (17 million people) of the population has a fear of using the toilet away from home, although it is uncertain how many of these fears were related to the difficulties initiating urinating in public bathrooms. The observed variation in these rates of paruresis is most likely related to whether significant life interference was required in order to be considered as meeting criteria for paruresis. There is no clear estimate about this disorder on a worldwide basis, though it seems to be a serious problem in many other countries.
What symptoms are associated with paruresis?
Here is one description of how paruresis operates in a person's life: After an initial unpleasant experience, the individual anticipates difficulty urinating whenever entering a bathroom. Forcible attempts to control the process fail, and associated anxiety with performance reduces the individual's chances of urinating while in a public facility. The paruretic must then adjust to the disorder by urinating as much as possible when at home, restricting the intake of fluids, locating vacant public bathrooms and refusing extended social invitations to avoid urinating away from home.
Paruretics engage in avoidance behavior, which temporarily reduces the fear associated with an inability to urinate but reinforces the phobic pattern. While some paruretics deny feeling any overt anxiety in public bathrooms and insist that they merely can't initiate urination, others do report physiological symptoms of anxiety, including heart palpitations, sweating, dizziness, faintness and shaking.
Since this topic is rarely talked about publicly, many paruretics feel that they are the only ones suffering from it. They feel ashamed of their disorder and become experts at hiding it from their closest friends, spouses and even their physicians. The sense of shame, humiliation, isolation and secondary depression resulting from this situation can be debilitating.
How is paruresis treated?
Many people with paruresis first visit a urologist to find out if there is something physically wrong with them, and it is clear that the function of a urologist is particularly important.
The urologist's role is to: 1) make certain there is no underlying physical ailment; 2) reassure the patient that he or she is not alone; 3) discuss behavioral approaches such as scheduling urination, and, for men, using a private toilet rather than a urinal; 4) teach the patient, if he or she so desires, self-catheterization; and 5) refer the patient to a specialist in anxiety disorders for cognitive and graduated exposure therapy.
Of these five treatment methods, self-catheterization provides an immediate way to relieve patients of their problems and improve their quality of life. The minimal risk in otherwise healthy and intellectually capable individuals far outweighs the harm done by permitting continued disruption of the patient's life.
No controlled studies of the treatment of paruresis have been published. However, behavioral exposure therapy has been reported to be helpful in several case reports over the last 40 years, with either complete or partial success. Other methods that have been used in the treatment of paruresis, with mixed results, include medications, hypnotherapy, paradoxical intention, sphincter botulinum toxin injection and surgery (i.e. transurethral microwave therapy (TUMT) or transurethral resection of the prostate (TURP).
Based on a limited sample, paruretic sufferers may also benefit from adjunct drug therapy. For some, the selective serotonin reuptake inhibitors (SSRIs) have seemed to help reduce anxiety levels enough that graduated exposure therapy began to work well. However, it is important to note that the effectiveness of any drug therapy in helping people with paruresis is purely speculative at this point. Interestingly, one standard urological treatment—the prescription of alpha-blockers—has not been proven to be effective for this disorder at this time.
What can be expected after treatment?
Assuming reassurance of the common nature of this problem and the proper and effective treatment of paruresis, most people can expect significant relief of their symptoms. While the disorder may occasionally come back, the patient, when properly educated, will not be alarmed by it, and will take appropriate measures to bring it under control again. Cognitive behavioral therapy seems 80 to 90 percent effective for paruresis, and with adjunct drug therapy, the disease is usually kept under control.
Frequently asked questions:
Is paruresis hereditary?
There is some evidence indicating that paruresis might be hereditary. It is important for parents to realize that if one or both have this condition, the likelihood is increased that your child or children could develop it as well.
Where can I get more information?
Kessler, R.C., Stein, M.B., & Berglund, P. (1998). Social phobia subtypes in the national co-morbidity survey. American Journal of Psychiatry, 155, 613-619.
Reviewed: January 2012
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