The inability to urinate in the presence of others.
Paruresis, also known as shy or bashful bladder, is the inability or difficulty to urinate in the presence of other people, when under time pressure, or on vehicles such as trains or airplanes. Urination is normal when those constraints or factors are absent, typically when in the bathroom at home. Research suggests up to 17 million Americans, 3.25 million Canadians, and 51 million Europeans suffer from the social anxiety disorder. Paruresis ranges in intensity from mild, in which the person can urinate in public facilities under certain circumstances, to severe, in which the person can only urinate when alone at home. The condition almost exclusively affects males although it can occur in females.
Paruresis can be socially disabling and can often completely take over a person's life. Examples include avoiding travel, social functions, and sports arenas. Just as serious are the psychological consequences, such as depression, and anxiety. Job choices and career decisions are often adversely affected. People with the condition often avoid jobs where there is mandatory drug testing done by the supervised collection of a urine sample.
Causes and symptoms
Paruretics (people who suffer from paruresis) commonly refer to three triggers that influence them when in public restrooms. For the typical paruretic, these triggers must be removed, or the person must try another toilet, for urination to occur on a particular occasion. First, the condition occurs much more frequently when strangers are present in the restroom as opposed to friends or relatives. Second, proximity plays a role in the problem. Proximity for the paruretic is both physical, involving the relative closeness of others in or near the restroom, and psychological, involving the need for privacy. The most frequent complaint about physical stimuli in public facilities is the absence of suitable partitions and doors on urinals or stalls. Third, temporary psychological states, especially anxiety, anger, and fear can interfere with urination.
The condition is diagnosed on the basis of the sufferer's account of their symptoms. In severe cases, sufferers can waste considerable time waiting for everyone else to leave the toilet before they can urinate, and might totally avoid urinating in public toilets. The condition is usually self-diagnosed when any or all of the three main triggers of paruresis are present and the condition is chronic.
The most well documented current treatment is based upon cognitive-behavioral therapy, of which the aim is to reorganize the "abnormal" emotional schemes arising from the anxiety generating elements that trigger this problem. This can be done individually in a self-help situation, in a support group, or through psychotherapy with a psychologist or psychiatrist.
Therapy includes three separate but linked components:
- Cognitive—An attempt to modify the abnormal thoughts and ideas around the object of anxiety, such as the thought, "When I use a toilet, everybody looks at me and wonders what I'm doing."
- Behavioral—Step by step desensitization by very gradual exposure to the feared situation, the aim being to achieve a series of small successes, and thus reassure the subconscious mind that it is "safe" to urinate in a situation that previously led to panic and failure. This can be thought of as relearning urination in a social situation.
- Relaxation—Learning techniques that facilitate relaxation, both mental and physical, such as sphincter relaxation exercises.
Drug treatments, usually with medications used to treat benign prostate hyperplasia (BPH), an enlargement of the prostate gland, such as terazosin (Hytrin), tamsulosin (Flomax), and alfuzosin (Uroxatral) are the subject of much debate and usually produce poor results.
One possible alternative medicine treatment is saw palmetto, used to treat urinary problems in men with BPH, an enlargement of the prostate gland. BPH results in a swelling of the prostate gland that obstructs the urethra. This causes painful urination, reduced urine flow, difficulty starting or stopping the flow, dribbling after urination, and more frequent nighttime urination. A typical dose is 320 mg per day of standardized extract. It may take up to four weeks of use before beneficial effects are seen.
Most people who suffer from the condition never seek help or treatment. Many never even discuss the problem with anyone. But anecdotal evidence suggests that those who do seek help have a good success rate at overcoming their fear or anxiety over time, sometimes a year or longer.
There is no known way to prevent a person from developing paruresis. Anecdotal evidence suggests it often does not occur until around the age of puberty. One suggestion for prevention is to condition children from an early age to urinate in public restrooms.
Benign prostate hyperplasia (BPH)— Enlargement of the prostate gland.
Psychotherapy— The treatment of mental disorders by psychological methods, usually by a psychiatrist or psychologist.
Sphincter— A circular band of muscle that surrounds an opening or passage in the body and narrows or closes the opening by contracting.
Urethra— The tube in humans that carries urine from the bladder out of the body.
Landers, Peter. "Looking for Relief: Shy Bladder Syndrome is Widespread; But in Many Cases it Can Be Treated Successfully." The Wall Street Journal (April 22, 2003): R5.
Siwolop, Sana. "For Some, Drug Tests Are Almost Impossible." The New York Times (April 14, 2002): NJ1.
June 11, 2001. WebMD The Secret Social Phobia. http://my.webmd.com/content/Article/14/1674_51491.htm. (Accessed March 31, 2005).