AUA Summit - What is Paruresis?

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What is Paruresis?

Paruresis, often called "shy bladder" syndrome, is when you have trouble passing urine when other people are around. Based on how serious it is, some people are not able to void without some or total privacy. In some ways it is like urinary retention, where you "cannot go." But the key difference is that shy bladder is not caused by a physical blockage.

Shy bladder can change your quality of life in many ways, causing problems with:

  • work issues (getting a urine sample for drug testing)
  • traveling on long plane rides
  • everyday social situations

How Common is Shy Bladder Syndrome?

While there is no way to know how many people have problems voiding in public, surveys in the last few decades show that it may be more common in Americans than you think. But it is not clear how much of this fear is about trouble voiding in public bathrooms.

Causes

There are many unanswered questions about the causes of shy bladder. It can affect a toddler in preschool, someone in their early or late teenage years or even in mid to late adult age. While some people cannot point to any single cause, others believe it was due to something that happened before or during the teen years, such as:

  • being embarrassed by a parent
  • being teased by classmates or siblings
  • being harassed in public bathrooms or being sexually abused

Though many people go through varied types of embarrassment, not all people get shy bladder. Recent research in the field of neurology shows that there may be physical as well as mental or emotional aspects of the problem. There is also some proof that shy bladder might be passed down from parents to children.

Symptoms

Here is one picture of how shy bladder can shape your life:

After a first unpleasant experience, you expect to have trouble voiding when you enter a bathroom. Trying to force yourself to void doesn't work. Then worrying about it makes it even harder to void. You make some changes like:

  • voiding as much as possible when at home
  • drinking less fluid when you know you will be away from a comfortable bathroom for a long period of time
  • finding empty public bathrooms
  • cutting back your social life so you don't have to use bathrooms away from home

People with shy bladder use avoidance behavior, which lessens the fear around problems voiding. But this only makes the pattern of fear stronger. Some people deny feeling any worry in public bathrooms and insist that they simply have trouble starting to void. But others have signs of anxiety like a rapid heartbeat, sweating, faintness and shaking.

Since this topic is rarely talked about openly, many believe they are the only ones suffering from it. They feel ashamed, and become expert at hiding it from their friends, spouses and even their health care providers. The sense of shame and depression can be a lot to handle.

Diagnosis and Treatment

Many people with shy bladder first visit a urologist to find out if there is something physically wrong.

The urologist's role is to:

  • check to make sure there is no related medical issue
  • assure the patient that they are not alone
  • suggest changes such as scheduling voiding and, for men, using a private toilet rather than a urinal
  • teach the patient self-catheterization
  • send the patient to a specialist in anxiety disorders for cognitive therapy and graduated exposure therapy

Of these approaches, self-catheterization leads to relief right away and better quality of life. The low risk for healthy people in using catheters far outweighs the harm of ongoing disruption of one`s life by shy bladder.

No controlled studies of the treatment of shy bladder syndrome have been published. But behavioral exposure therapy (exposing you to what you fear) has been said to be helpful. Other methods that have been used with mixed results are:

  • medications
  • hypnotherapy
  • paradoxical intention (worrying on purpose)
  • sphincter botulinum toxin injection (to control muscle activity)
  • surgery or procedures on the prostate

People with shy bladder may also benefit from medication therapy that is not specific to urology. For some, antidepressants (like selective serotonin reuptake inhibitors) help reduce worry so that behavior therapy can start to work. But it is of great value to note that medication therapy for shy bladder has not been proven to work well. Interestingly, the standard urological treatment with alpha-blockers has also not been proven to work at this time.

After Treatment

Knowing that this problem is common and with the right care, most people with shy bladder can expect relief. While this health issue may come back, with proper measures it can be controlled again. Cognitive behavioral therapy seems to be an effective treatment method and along with medication therapy, shy bladder can often be controlled.

Updated May 2024. 


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