Paruresis – often known as ‘shy bladder’ or ‘bashful bladder’ – is a social anxiety disorder that can affect both men and women. The sufferer is unable to urinate in the presence of others – for example in a public toilet such as at work or in restaurants, or in toilets in other people’s houses. A person with this disorder is known as a paruretic.

Although lots of people experience ‘stage fright’ where they have difficulty urinating in undesirable or uncomfortable situations, this is different to paruresis. Paruresis is far more serious and may cause physical problems. Although the problem is a psychological problem, the physical effects of it are unable to be controlled by the sufferer.

History

Although literature suggests paruresis has been around for a long time, the term was first named by a paper by Willaim and Degenart in 1954. The paper was entitled “Paruresis: a survey of disorder of micturition” and was published in the Journal of Psychology. The paper surveyed 1,419 college students and discovered that 14.4% of them had experienced paruresis – either continuously or incidentally. Interestingly, there is no data available about paruresis before this time – a good example being World War 2. The conditions and the lack of privacy in training and fighting would have been intolerable for paruretics however there are no accounts of men dodging the draft due to this condition, going AWOL or obtaining psychiatric discharges.

What are the major problems for people with this problem?

The NHS and government are beginning to recognize this problem – the NHS on-line encyclopedia of conditions and disorders now lists this condition. Paruresis is also catered for in the rules for mandatory testing for drugs in UK prisons. UK incapacity benefit trials also recognize this condition. It is now also reportedly a valid reason for jury service excusal. With workplace drug testing becoming more common, this can also prove to be an obstacle. However in the UK, employees have the right not to be unfairly dismissed if the company does not recognize and cater for this condition.

Severe cases of this disorder can be highly restrictive on the sufferer’s life – severe sufferers may not be willing to travel far from their home, or able to go out for meals and days out such as camping or outdoor concerts. Some people are unable to urinate in their own home if someone else is there. Strategies which may be employed by sufferers include:
- Drinking less fluid. This is dangerous as it can lead to dehydration
- Avoidance of large or busy public toilets and only emptying out when ‘safe’
- Trying to find less-busy or single cubicle toilets
- In the case of men, finding a stall instead of a urinal
- Running a tap or flushing the toilet to mask the sound of urination

If a user is unable to urinate and the bladder is held at a very full level for a long period of time, it can lead to internal infections and severe stomach pains.

The strategies outlined above only address the symptoms and do nothing towards curing the problem. Treatments which aim to cure the problem, or alleviate the symptoms include:
- Cognitive behaviour therapy: with the help of a therapist, recognizing the patterns and replacing the reaction of ‘seizing up’ with a more helpful action.
- Biofeedback: a complementary therapy which monitors bodily processes such as heart rate and skin temperature to provide access to the sufferer about their physiological information so that they can gain control over physical processes which are normally considered ‘automatic’.
- Use of a catheter: although more of a ‘work around’ than a cure, it helps to alleviate the symptoms
- Drug treatment: in some cases, medication is necessary especially when depression or serious anxiety problems are present. Some medication can help the sufferer to relax more hence alleviate some of the symptoms.
- Gradual exposure therapy: reducing the level of privacy slowly to help the sufferer feel more comfortable. This therapy is normally employed at workshops so that sufferers can work together.

A simple explanation is that we can imaging that it is based on a reflex between strain sensors in the wall of the bladder and flow sensors in the urethra and the detrusor. The strain of having a full bladder triggers it to contract. The flow sensors detect when there is a flow of urine and feeds back to the bladder sensors to ensure the bladder stays contracted whilst there is urine still flowing. For adults, this reflex is a conscious reflex which is controlled by the brain. However, the co-ordination of the micturition and continence are subconsciously controlled and are integrated into other bodily processes.

Generally, micturition can be started on command nearly every time however a delay is observed in most people when in the presence of others. Causes of this include the detrusor not contracting sufficiently or a resistance in the flow through the urethra. This is usually caused by stress which causes the detrusor to relax and the sphincters to tighten. The syndrome is nearly always a social phobia and only rarely is a physical problem found.

If the cause is not addressed and the syndrome is fairly severe, dangerous conditions can occur – from the frequent need to urinate, blood in the urine and stomach pains. If you find you display any of these symptoms, it is imperative to visit a doctor for further investigation before you damage your health permanently.

When the sufferer starts to show the symptoms, they will start to catastrophise. They will start to become anxious about not being able to urinate the next time they are in a public bathroom. Each time they fail to urinate, the anxiousness will rise meaning urination will become more and more difficult.

Because of this, the only ‘safe’ place will usually become the bathroom at home. Those with the most severe form of paruresis will find even this is not always safe – if someone else is in the house, they may experience problems urinating. Paruretics will try to adapt to their situation by urinating as much as possible at home and trying to avoid urinating in public bathrooms by restricting fluid intake. They may also refuse social invitations. Restricting fluid intake is extremely dangerous and can result in severe health problems. Paruretics will also try to perform checks to try and locate vacant toilets whenever they can. Common ways to try to help themselves urinate are to think of water, to run a tap or to flush the toilet whilst they urinate – both to encourage urination and to mask the sound.

As your bladder fills, the dome around the bladder relaxes and both of the sphincters contract. As you urinate, both the sphincters relax and the dome around the bladder contracts so that the urine is forced out with minimal resistance.

The external muscle can be controlled consciously. However even muscles consciously controlled can seize up, particularly when we are anxious or stressed. If you could get this sphincter back under control, you may be able to learn to urinate more freely.

One method we can use is to focus on the muscle. Ensure that you are in a quiet place where you feel relaxed and comfortable.
Contract the sphincter muscle as strongly as you can so that you are aware of it’s position.
Relax the muscle.
Now to try and relax the sphincter more. Focus on the muscle and focus on relaxing. You should find that you are able to relax the muscle more than you expected to.
Repeat this exercise a few times a day and try to get the muscle as much under control as you can.
After a few days, try to imagine a situation where you do not feel comfortable. Now try to relax your sphincter muscle.

When you try this technique in a real situation, if the flow does not start, try to push a little bit with the muscles of the abdomen. If your sphincter is totally relaxed, the flow of urine should start. If you still have problems, relax, and continue to practice the exercise a little while longer before employing it in a ‘real life’ situation again.