It is important that you check the dosages on all the following remedies as products from different manufacturers may contain different amounts of the active substances, and concentrations in different batches may also vary (even if they come from the same manufacturer).

St. John’s Wort
St. John’s Wort is sometimes known as hypercium. It has been used for centuries to treat anxiety and it is commonly used throughout the World. The flowers and leaves of the plant are used to make the remedy - they contain a substance called hypericin and it is this substance which is believed to help alleviate anxiety.

There have been recent reports that St. John’s Wort may adversely affect your kidneys and/or liver so check with your doctor before taking it.

Kava-Kava
Kava-Kava is made from the pepper plant ‘piper methysticum’ which is found in Polynesia, Melanesia and Micronesia. It is made from the root, ground down to a powder. Kava-Kava is most commonly used to aid relaxation and produce a contentment and occasionally a mild euphoria.

Please note that Kava-Kava is banned in the UK because of possible toxic effects on the liver.

Saw Palmetto
Saw Palmetto, otherwise known as Serenoa repens, is often used as a treatment in benign prostatic hyperplasia (BPH). It also known as Sabal serrulatum, Sabal serulata, Sabalis serulata, Sabalis serulatae, Serenoa serrulata and Serenoa serrulatae.

Saw Palmetto has been used for over 100 years to treat swollen prostates. For this reason, it may be beneficial to men who are suffering from paruresis.

Using a catheter should be painless, quick and easy. Depending on the diameter of the catheter and the amount of urine in the bladder, it may take up to two minutes for all the urine to be passed. You will know when your bladder is empty as no more urine will flow.

Catheters are small therefore can be carried in a handbag, pocket or luggage with no problems. Many people will carry lubrication jelly and handwipes with the catheter in a small cosmetics-type bag. Most people like to lubricate the catheter with lubrication jelly – note that Vaseline should never be used. There are some catheters that do not need lubrication – which brand to use is personal choice.

Catheters comes in a variety of styles, materials and sizes. You may need to try a few catheters out to find what is most suitable for you. Common catheter materials are silicone, plastic, rubber, PVC or Teflon. Some catheters also have tapered tips to help with insertion. Some also have a slight bend near the tip and are know as Coude catheters – men often prefer to use these.

You should always get fully trained in how to use a catheter before using them as you can damage yourself if it is incorrectly inserted. Your local doctor or nurse should be able to help teach you how to use one correctly.

Catheters are widely available. You should be able to get them at pharmacists, on-line, mail-order or medical supply stores. No prescription should be necessary. Both reusable and disposable catheters can be used. Reusable ones just need to be washed with water and a little soap.

It is better to lead them in gently than drop the issue on them. You might want to start with something such as:
“I have a phobia which is really messing my life up. It is an illogical fear. So far, I’ve been too embarrassed to tell anyone. I have a social phobia rather like stage fright - like when you are unable to speak when other people around. For me, when people are around, I lose the ability to pee. I want to go but I’m unable to. It often makes my life a misery. It is a recognised condition called ‘paruresis’ and lots of people have it, but it’s not something which many people talk about.”

This dialogue will lead them gently into the problem and give them something they may be able to relate to before you tell them the problem outright. It also lets them know that paruresis is a real condition which is recognised by organisations such as the NHS. They may even offer you to try and help you get over the condition.

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.

Female bathrooms are usually treated differently to men’s. That old adage that women go to the bathroom in pairs holds true - women’s bathrooms tend to be more of a social area than men’s, with women talking between the stalls, doing their make-up and hair in the mirrors, taking in small children (who can be disruptive) and changing babies nappies. For these reasons, women’s bathrooms tend to have longer queues. Both the queues and the social aspect of the bathrooms mean extra difficulties for female paruretics because they dislike being rushed and dislike other people being around meaning these types of situations can cause extra anxiety.

What can women do to help themselves?

Relax!

The first thing to do is relax! Being tense will only make it harder for you to urinate. Breathe slowly and deeply. Relax your abdomen; Breathe in through your nose, hold your breath for four seconds, and then breathe out slowly through your mouth. Relax your stomach muscles so that you reduce the pressure on your bladder.

Focus

Non-sufferers will focus on the cubicle that they are headed for. Sufferers will focus on the people in the bathroom. Discipline yourself to put ‘blinkers’ on and focus only on where you are heading. Deliberately ignore anyone else in the bathroom.

Hesitancy

Remember that hesitancy is normal - hesitancy is the delay between being ready to urinate and the flow actually starting. Everyone has a different hesitancy length. Time yourself at home so that you know what is normal for you. Most people, even those who do not suffer from paruresis, will find their hesitancy time increases when they are unknown places, so if you find yourself suffering from slightly longer hesitancy, remember it’s normal!

Positive thoughts!

Control your negative thoughts to reduce anxiety. If one appears, clear it from your mind. Recognize the thought is negative and tell yourself the thought is not based in reality. Think of a positive thought to replace it and repeat it to yourself - “I can always try again later”, or “There are more interesting and important things on my mind right now”. The important thing is to think of something positive so that no more negative thoughts can arise.

Wait it out

If you still cannot go, wait it out. If other people are in the bathroom, wait for them to leave. Contrary to what you may think, no one will notice or care what you are doing. It’s your personal space and you are entitled to it.

Talk about it

Try talking to someone that you trust - maybe a partner or a friend. You are suffering from a social anxiety so let them know so that they can support you. Emphasize how much this affects your life and let them know you would appreciate it if they covered for you if you take a long time in the bathroom, or if they thought about where and how long you go out for. Log onto our forum and talk to other sufferers.

Other ways to help yourself.

Desensitization

Desensitization is the process where you desensitize yourself to the environment. Experience normal conditions. Most sufferers do not know what passes for routine behaviour because they are so anxious when they do go into public bathrooms. Start by entering the bathroom and just washing your hands or checking your make-up. Do this a few times over a period of time. You will soon see that no-one is focused on you! Soon, this will become boring. Now, start to use the toilet. If you are unable to go within about two minutes, leave, otherwise you will start to enforce the anxiety.

There are workshops designed especially for women which can help with the desensitization process.

Catheters

Self catheterization is where a sterilized plastic tube is inserted into the urethral opening to allow the release of urine. This can be a difficult process for women. It is not a cure for the problem but may help until the underlying causes of the affliction are cured.

Catheters come in a variety of sizes, styles and materials. It is important to find one which suits you so that you can feel happy using one. Because of the variety, it is a good idea to go to a health care practitioner to ensure you find the catheter which is best suited to you.

There are a few different methods for inserting a catheter. The method which is most used is to sit or stand over the toilet bowl and identify the opening of the urethra by feel. The catheter is then inserted and the urine is drained. If you have problems inserting the catheter, there are products on the market which can help identify the opening. Again, visiting a health care practitioner is advisable so that they can show you a range of methods which you can try.

Women are more susceptible to infections of the urinary tract such as cystitis than men. If you do decide to use a catheter, it is advisable to drink plenty of fluids (especially water) and to urinate frequently. This, of course, is a catch-22 for a paruretic! Antibiotics can be prescribed as a preventative measure, and can also be prescribed if you do get a urinary tract infection.

What else can I try?

You could try a urinary pouch. This is a plastic bag which attaches to the inner thigh which has a valve at the bottom to release the urine. If you wear a skirt or loose fitting trousers, it will be totally hidden.

There are also assistive items which can be used, although they are recommended more for outdoor use (such as camping). They are ‘funnels’ which enable a woman to urinate through the flies of their trousers whilst standing up.

Your local GP may also be able to prescribe you something to help to reduce your anxiety levels - common prescriptions are SSRIs such as Prozac or Paxil.

Why is paruresis more common in men than women?

There is no underlying reason why men are more likely to suffer than women, however there may be a few reasons why men appear to suffer more than women.

Some women may suffer in silence believing it is an inconvenience that they just have to put up with.

Media attention has primarily been focused on men with paruresis so women may not be aware that they can suffer from the condition too.

Some women may not wish to participate in mixed discussion groups.

Women tend to be more inhibited when it comes to talking about the condition. Many forums are male-orientated and women may be put off by the lack of other women to talk to. They may also be reluctant to talk about personal problems with strangers.

What else can I do?

Read! Although, as mentioned above, most literature is aimed at men, you will learn a lot about the condition and you will find there are many sufferers out there. Come and register on our forum (remember, you do not have to use your real name, or give it out to anyone, so no one else will know who you really are) and talk about techniques which work for you, and what you are doing to help yourself!

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.

Relax!

Being tense makes it more difficult to urinate. Ensure that you breathe slowly and deeply, fully relaxing your abdomen. Deep slow breathing will calm you down and help you to relax. Breathe in slowly through your nose and hold for four seconds before breathing out slowing through your mouth.

Lean slightly backwards until your thigh muscles are not tensed. Bend your knees slightly. Let your shoulders relax. Scrunch them up to your ears and then drop them down again.

Anxious people often tighten their abdomen which puts pressure on the bladder. Try to relax your stomach muscles.

Understand your hesitancy

Hesitancy is the delay between being ready to go and the flow actually beginning. Hesitancy is normal and everyone has a different hesitancy length - from milliseconds to up to 15 seconds. When you are in a relaxed environment, time yourself to find what your normal hesitancy is. Most people, even those who do not suffer from paruresis, find that their hesitancy increases in unknown places. Some may even not be able to go at all, however they do not see this as a problem. So, you will also find that your hesitancy length will increase whenever you are not home - it is entirely normal!

Stop the negative thoughts

Try to control your negative thoughts. The moment a negative thought pops up, try to clear it from your mind. Relax, and breathe slowly. Recognize the thought as negative and say to yourself it is not based in reality. Now try to think of a positive thought - ‘I can always try again later’, or perhaps ‘I have more interesting things on my mind right now’. The important thing is to focus on something other than the negative thoughts so no more can arise.

Remember, whatever you may think, no one else is judging you. They are not interested in you - they have other things on their mind!

Wait it out!

If other people are in the bathroom with you and you are unable to go, wait it out. They will eventually leave. Contrary to what you may think, no-one will notice or care. In fact, the busier the place, the easier it is to wait it out. Most men avoid standing next to each other at urinals unless there is no choice. In this situation, many will choose to use a cubicle anyway. It’s your personal space and you are entitled to do so! If someone does look up at your as you walk by, they are not thinking about you! It is an automatic reaction to see what has gone past and is in no way a judging look.

Tell people

Tell someone you trust - it is a social anxiety and they will be able to support you through it. Ensure that you emphasize that it affects your life and your peace of mind. Let them know that just them knowing about it takes the pressure off you. You can also let them know that they can help you by taking your needs into account - about when and where to go out and how long to stay out, and to cover for you if you take a long time.

When you go out, desensitize yourself to the environment. Experience normal conditions. Most sufferers don’t know what passes for routine behaviour in public toilets because they are so fearful when they do go, they do not notice. Go into the public toilets - maybe to just wash your hands. You will soon realise that no-one cares. Soon, it will become boring and you will be desensitized. Now you can start to use the toilet. If you find yourself becoming anxious, leave the toilet as you do not want to reinforce the anxiety.

Nerve Stimulation (for men only)

Some men have a nerve which, when stimulated, can cause them to urinate substantially. It is located in the bit of the penis sking which anchors the shaft sking to the underneath tip of the penis. If you are uncircumcised, you will need to retract the foreskin. Just a slight touch can cause an urge. Tickling the base of the spine just above the coccyx can also help both men and women.

Focus

Non-sufferers will focus on the cubicle or urinal they are headed for when they enter the toilet. Sufferers will tend to focus on the people in the toilet and everything which is around them. Discipline yourself to focus on where you are going to and deliberately ignore anyone else who may be in the toilet with you.

Try again later

If you are unable to go after 2 minutes, leave and try again later, otherwise you will reinforce the negative anxiety.

Before you begin, it is advisable to seek out a doctor’s advice first to ensure that your symptoms are not caused by something physical. As a general rule, you have paruresis if you are able to go at home easily but you find it difficult to go or are unable to go in social situations.

Exposure Therapy involves several sessions. Each session will involve several attempts at urinating. This means that a substantial amount of urine is needed. Because of this you must try to drink a lot of fluid (preferably water) before the session. Most people will only be able to succeed using this therapy if their need to urinate is high at the time of the session - it is a good idea to try and ensure that the urgency is fairly high, but not extreme.

It is also important to try and have a back-up plan. The most common of these is the use of a catheter. Ensure that you are comfortable using a catheter before you start the exposure therapy sessions.

In your first session, you will need an isolated bathroom where you feel comfortable. Ask your buddy to wait away from the bathroom but on the same floor - somewhere where they will not be able to hear you urinate. Once your buddy is in place, try to urinate. If you are able to star the flow, continue the flow for 3 seconds and then stop. Take a break for 5 minutes. Now, try again. If you are a paruretic who does not like the noise of urination, try to make your urine flow as loud as possible to desensitize yourself to the sounds. Do not use any background noises such as a running tap as you go. If you are unable to urinate after 2 minutes, take a break for 3 minutes and then try again. If you are still unable to urinate, have your buddy move further away - maybe a different floor or even outside the house. Remember it is also important to relax - check out our relaxation techniques with hints and tips on how to do this.

When you have successfully urinated a couple of times, move your buddy closer. Typical ’steps’ are:
- Just outside the bathroom door with the door locked
- Just outside the bathroom door with the door unlocked
- With the bathroom door slightly ajar
- With the bathroom door wide open
- Standing just inside the bathroom
- Standing directly behind you.

If you do not have a buddy to practice with, or you have reached the ‘top step’ with your buddy, try setting yourself a series of steps such as:
- Trying to go when people are outside the bathroom
- Trying when there is one person in the bathroom
- Trying when there are multiple people in the bathroom
- Trying when someone is in the stall next to you.

With each step, after you have successfully urinated a couple of times, move up to the next step. The ideal which you are aiming for is being able to urinate freely in a public bathroom with a lot of people in the bathroom with you.

If you find one step is giving you a lot of bother, try breaking the step down into smaller steps. Just a couple of centimetres can make the difference and will help to boost your confidence.

For the best results, it is advisable to practice several times a week for up to an hour. Longer sessions are generally more helpful than shorter ones. You may need to keep drinking fluids throughout the session to ensure that you have enough urine. Be prepared for some inconsistency in your progress - it’s entirely normal! Most people will experience ups and downs with how close they can let their buddy get to them in each session and it is nothing to concern yourself about.

This therapy normally takes around 12 sessions, although each person will be different - some people will require more sessions, some less. It is important to go at your own pace. Although this treatment has helped many people overcome their paruresis there is no guarantee it will cure yours. Check out the other pages on our site to see if there are other techniques that can help you.

On extremely rare occasions, you may find that you are unable to urinate even after your buddy has gone home and you are on your own. If this happens it is imperative that you seek medical treatment immediately otherwise you risk damaging your health.

If you feel that you have tried all the self help available, seek advice from your doctor who may be able to advise you on other techniques to try, or may be able to prescribe you medication to help lessen your anxiety.