Shy bladder syndrome

About paruresis

A person with paruresis (shy bladder syndrome) finds it difficult or impossible to urinate (pee) when other people are around. Paruresis is believed to be a common type of social phobia, ranking second only to the fear of public speaking. Paruresis is often first experienced at school.The condition affects men and women of all races. In mild cases, paruresis is an occasional event, like a form of performance anxiety. For example, a man at a public urinal may find that he is unable to urinate when flanked by other men. In severe cases, a person with paruresis can only urinate when alone at home. The condition is also known as ‘avoidant paruresis’, ‘psychogenic urinary retention’ and ‘pee-phobia’.

Symptoms of paruresis

A person with paruresis typically has a sensitive, shy, conscientious personality and is fearful of being judged or criticised by others. Paruresis can be mild, moderate or severe.

Signs and symptoms of severe paruresis can include:

• the need for complete privacy when going to the toilet
• fear of other people hearing the urine hit the toilet water
• fear of other people smelling the urine
• negative self-talk while trying to urinate, for example: ‘I can’t do it. I’m never going to pee. I’m such an idiot.’
• inability to urinate in public toilets or at other people’s homes
• inability to urinate at home when guests are present
• inability to urinate at home if someone is waiting outside the toilet
• feeling anxious about needing to go to the toilet
• restricting drinks to reduce the need for urination
• avoiding travel and social events.

Similarities to agoraphobia

Severe paruresis can affect a person’s life in a similar way to agoraphobia, which is anxiety about being in places or situations from which escape seems difficult (typically, fear of crowds or being outside the home).

If a person can only successfully urinate when home alone, they may avoid leaving the house. This can reduce quality of life and curtail job opportunities.

Cause is psychological

Paruresis is not a physical condition because nothing is wrong with the person’s urinary tract. The urinary sphincter must be relaxed for urine to flow from the bladder down the urethra. Anxiety about urinating overstimulates the person’s nervous system and ‘clamps’ the sphincter shut. Failure to urinate heightens the person’s anxiety, particularly if the bladder is uncomfortably full.

For some people, an embarrassing incident starts the social phobia – for example, the inability to urinate into a cup in front of a doctor or nurse. Worrying about the embarrassing incident makes the person feel anxious about urinating in the presence of others.

Diagnosis methods

Various physiological conditions can hamper urination. Prostatitis, for example, can make urination difficult for affected men. The doctor will usually perform a series of tests to make sure that nothing is physically wrong with your urinary tract.

Generally, the diagnosis is paruresis if you can urinate successfully when alone at home. The doctor may suggest the short-term use of drugs such as tranquillisers or antidepressants. However, these drugs will only reduce anxiety, not cure the condition. In severe cases, the doctor may suggest that you learn self-catheterisation. A catheter is a slender tube inserted up the urethra and into the bladder to drain urine.

Treatment options

You may like to consider joining a paruresis support group. In severe cases, it may be helpful to see a psychologist. Treatment may include:

• Relaxation techniques – to learn a range of strategies to help reduce anxiety.
• Psychotherapy – a type of counselling that helps you deal with the here and now, and teaches problem solving.
• Cognitive behavioural therapy – changing the way you think and behave.
• Graduated exposure therapy – a step-by-step program that involves deliberately trying to urinate in increasingly more difficult places. About 8 people out of every 10 with paruresis are helped by graduated exposure therapy.

Graduated exposure therapy (systematic desensitisation) explained

Be guided by your psychologist, but if it’s felt that graduated exposure therapy will be helpful for you, your therapist will usually ask you to:

• Make a ranked list of urination locations from easiest to most difficult. For example, most people with paruresis find it easiest to urinate at home alone. The hardest location is usually a crowded and noisy public toilet. The idea is to start with the easiest locations and work your way up in degrees to the most difficult.
• Have a ‘pee partner’ to support you. This could be a family member or trusted friend.
• Ask your pee partner to stand as close to your home toilet as you feel comfortable while you are trying to urinate. Urinate for a few seconds then stop for a few minutes.
• Have your pee partner stand a little closer to the toilet. Go back into the toilet and urinate again for a few seconds, then stop.
• Keep practising, with your pee partner getting closer and closer to the toilet. This may take several sessions over a period of time.
• Try to make as much noise as possible while urinating. Deliberately splash your urine into the toilet water. Do this with your pee partner nearby.
• Pick a quiet public rest room (once you are comfortable with urinating at home) and then, with your pee partner standing outside the toilet door, practise the same way you did at home.
• Use your pee partner and work your way up the ranked scale of difficult locations until you can successfully urinate in a crowded and noisy public toilet.
• Graduated exposure therapy is more successful if it is practised often, perhaps three or four times per week.
• Drink plenty of water before your practice session to make sure that your bladder is full.
• Avoid any negative self-talk while trying to urinate. Remember that paruresis is a common social phobia. You are not abnormal or ‘the only one’.
• Take it slowly, step by step. Don’t pressure yourself. You should see considerable improvement after about 12 sessions or so.

Where to get help

• Your GP (doctor)
• OCD & Anxiety Helpline Tel. (03) 9830 0533 or 1300 ANXIETY (269 438)
• Anxiety Disorders Association of Victoria Inc. Tel. (03) 9853 8089
• George – Support Group Leader Melbourne, Paruresis Association of Australia. Email: antipodes7@yahoo.com.au