PARURESIS

For most people, going to the restroom to urinate is a daily activity that occurs without fear or impediment. However, for some individuals urinating in public restrooms is a significant source of anxiety and distress. This page will discuss the bladder anxiety condition known as paruresis (shy bladder syndrome).

WHAT IS PARURESIS?

Paruresis (also known as shy bladder syndrome) is a psychological condition characterised by a difficulty or inability to initiate or sustain urination (e.g., a public restroom), due to overwhelming fear of perceived scrutiny. Paruresis typically occurs in busy public restrooms (e.g., in shopping centres or restaurants). However, in severe cases paruresis can occur in private restrooms such as within one’s own home. The prevalence of paruresis has been reported to range between 2.8 and 16.4%, with males typically being affected in greater numbers than females. The onset of paruresis is often in adolescence.

The prevalence disparity of paruresis between genders can possibly be attributed to two reasons. The first reason includes genitourinary differences between males and females. While males tend to develop urinary retention (difficulties with urination) as they age due to benign prostatic hyperplasia (gradual enlargement of the prostate gland), females tend to experience weak bladder and urinary incontinence issues. The second reason includes differing layouts between male and female restrooms. Men are provided with standing urinals in male restrooms, while in female restrooms women are provided with closed cubicles that allow for personal space and physical privacy. As a result, men may experience greater difficulties with urination due to the lack of privacy and personal space.

WHAT ARE THE SYMPTOMS OF PARURESIS?

Individuals with paruresis experience a variety of symptoms ranging from physical to psychological. Paruresis sufferers experience anxiety around difficulties urinating and use of restrooms. These symptoms tend to worsen in severity when in public situations (e.g., restaurant and shopping centre restrooms), where paruresis sufferers perceive that they are being judged or criticised by others within the restroom.

Symptoms of paruresis range in severity and can include:

A noticeable difficulty or inability to initiate or sustain urination in public restrooms. In severe cases, paruresis sufferers will be unable to urinate when family and/or friends are present in the home.
Avoidance behaviours such as avoiding using public restrooms.
Only using public restrooms that are secluded and offer greater privacy.
Avoiding or limiting travel/use of public transport to decrease the need to use a restroom in public.
Avoiding social activities (e.g., dating, going to sporting events, parties) that may require the use of a public restroom.
Men using cubicles to urinate in as opposed to standing urinals.
Safety behaviours such as decreasing fluid intake to avoid using restrooms in public.
Anxiety related physical symptoms such as excessive sweating, a racing heartbeat, nausea, muscle tension, trembling, and blushing.

Individuals with paruresis tend to experience greater symptoms when there are more people present and in closer proximity (e.g., a busy public bathroom with a queue of people waiting in line). Anxiety levels may also depend on the privacy of the restroom, for example, using a standing urinal may cause more anxiety than urinating in a cubicle. Some people even report difficulty using the restroom in their own home, especially if they have guests over.

The difficulties associated with paruresis can have a significant impact on quality of life. Not only do sufferers notice that it impacts upon their social activity, but it also has consequences for their work. Anxiety regarding restroom use can influence the type of work environment that an individual is comfortable in, may affect whether they are willing to travel for work (e.g., airplane travel), and can also impact on roles that require workplace drug testing (e.g., aviators and athletes). Paruresis can also cause considerable shame among sufferers, with most individuals not seeking assessment or treatment due to embarrassment.

MODELS AND CAUSES OF PARURESIS

While there have been multiple theories (also referred to as models) of paruresis (e.g., psychodynamic, genetic, biopsychosocial, psychological, social, cognitive, behavioural, and cognitive-behavioural perspectives) research on these theories are limited, with the exception of the cognitive-behavioural theory which is the most widely accepted. According to the cognitive-behavioural theory, cognitive (e.g., a pronounced fear of negative evaluation) and behavioural features (e.g., use of avoidance and coping behaviours to reduce probability a public restroom) are present in paruresis and are consistent with other anxiety-based conditions, specifically social anxiety disorder.

Currently, paruresis is classified as a form of social anxiety disorder (also known as social phobia). Paruresis is noted to share similar psychological features with social anxiety disorder, with both conditions being closely related. Indeed, up to 22.2% of individuals with paruresis have been noted to also be afflicted with social anxiety disorder. Like individuals with social anxiety disorder, those with paruresis experience fear of being negatively evaluated by people around them (e.g., being negatively judged by other restroom occupants for the smell of my urine), and use avoidance behaviours (e.g., avoiding using restrooms in public) to reduce feelings of anxiety and distress.

Recently, Kuoch, Meyer, Austin, and Knowles (2019) conducted a study where they applied the extended bivalent fear of evaluation model of social anxiety (for more information about this model, click here) to paruresis symptoms. Their model identified that socio-cognitive processes such as fear of negative and positive evaluation, along with dysfunctional attitudes and concerns of social reprisals contributed to paruresis symptoms (see below for diagram and summary of factors predicting paruresis symptoms).

Dysfunctional attitudes: Pervasive negative attitudes that are held towards oneself, the outside world, and the future (e.g., people will probably think less of me if I make a mistake.)

Fear of negative evaluation: Distress from being unfavourably evaluated by others (e.g., I am afraid that people will criticise me for taking too long to urinate).

Fear of positive evaluation: Distress from being favourably evaluated by others (e.g., I generally feel uncomfortable when people give me compliments).

Concerns of social reprisals: Fear of being evaluated too positively by others, and the resulting reprisal that may ensue (e.g., I do everything I can to avoid envy from others who “out-rank” me, even in casual social situations).

The extended bivalent fear of evaluation model of paruresis

Kuoch, K. L. J., Meyer, D., Austin, D.W., & Knowles, S.R. (2019). Socio-cognitive processes associated with paruresis and parcopresis symptoms: A proposed bivalent model.
Current Psychology

Causes of paruresis

Regarding potential causes of paruresis, traumatic or stressful events related to restroom use have been argued to be contributing influences. For instance, individuals with paruresis may have experienced traumatic or stressful events in public restrooms during childhood or adolescence, such as being bullied or teased. After this traumatic experience, the individual may become stressed and nervous about using public restrooms which then leads to further anxiety and difficulties surrounding urination.

DIAGNOSIS OF PARURESIS

In the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; a manual used by mental health professionals to diagnose mental disorders), validated diagnostic criteria for paruresis has yet to be published. As a result, paruresis is currently diagnosed by excluding possible medical reasons for urinary difficulties and confirming that symptoms are due to a psychological cause.

If you are experiencing problems urinating, it is a good idea to see a General Practitioner (GP) to rule out potential medical issues. Your treating doctor may conduct a series of examinations to screen for physical abnormalities. It is essential that a medical examination is conducted as urinary difficulties can be a sign of physical illness (e.g., prostate enlargement in men leading to urinary retention symptoms).

Examination may include collection of a thorough medical history, physical examination, and use of appropriate diagnostic and investigative assessments (see below for further details).

Physical examination: During a physical examination, your doctor will press against your lower abdomen to feel for signs of abnormalities. For male patients, a rectal examination may be conducted to check for swelling of the prostate.

Blood test: A blood test may be ordered to help identify signs of infection that may causing symptoms. It can also be used to examine inflammation markers, and prostate specific antigen in men to screen for prostate cancer.

Urine culture test: A urine sample may be collected to help identify signs of infection in the urinary system.

Radiological investigation: Your doctor may refer you for urinary tract imaging (e.g., ultrasonography, magnetic resonance imaging, computed tomography, radionuclide scan) to check for obstructions in the urinary system.

Urodynamic testing: An array of urodynamic tests may be used to help examine the bladder and urethras ability to store and release urine. Tests may examine the volume, flow, and speed of urine, in addition to the bladder pressure required for urination to occur.

Ureteroscopy: A ureteroscopy involves inserting a cystoscope (a small, flexible telescope with a camera) through the urethra to examine the upper urinary tract. This examination will allow the doctor check for physical abnormalities within the urinary tract (e.g., scar tissue or stones, tumours causing obstruction).

Neurological investigation: Your doctor may refer you to neurological investigation (e.g., electromyography) to identify whether urinary retention symptoms are due to neurological dysfunction.

TREATMENT OF PARURESIS

Once potential medical causes have been eliminated, the treating doctor can arrange for a referral for psychological treatment. Some of the most common treatment approaches are listed below:

Psychological treatments

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) offers the most consistent evidence for the reduction of social anxiety. Given the presence of anxiety-related symptoms in paruresis and previous use of CBT to treat paruresis, CBT is one of the most accepted treatment options. CBT is a short-term focused approach to changing unhelpful thoughts, habits, and behaviours, and replacing them with healthier ones.

Graduated Exposure Therapy

Graduated exposure therapy is a common treatment for anxiety conditions and involves individuals being gradually exposed to their feared object or situation within a safe context. Exposure to the feared stimulus is gradual, so that the individual gradually confronts their fear until they no longer experience distress to their feared object situation. Graduated exposure therapy has been used to treat paruresis and is known to be an effective intervention.

Relaxation training

Relaxation training involves learning techniques that increases calmness and relaxation and decrease feelings of anxiety and stress. Several relaxation techniques are available, with some of the most popular including deep breathing, mindfulness meditation, progressive muscle relaxation, tai chi, yoga, and other forms of exercise.

Other potential psychological approaches to treating paruresis

Mindfulness-Based Stress Reduction (MBSR)

Mindfulness-based stress reduction is an eight-week program that involves intensive mindfulness (directing attention to experiences occurring in the present moment) training. This program was developed to support individuals experiencing anxiety, depression, stress, chronic pain, and stress related to medical conditions. Mindfulness-based stress reduction assists individuals to become aware of stressful or unpleasant feelings and stress reactions they may be experiencing. It allows individuals with anxiety, depression, or other afflictions to recognise their feelings in the current moment and enables them to react in a positive way.

Acceptance and Commitment Therapy (ACT)

Acceptance and commitment therapy is a psychological treatment program that uses acceptance (the process of recognising and accepting negative or uncomfortable situations without trying to change them) and mindfulness (focusing ones attention to experiences that are occurring within the present moment) strategies, with behaviour-change and commitment strategies. The aim of acceptance and commitment therapy is to recognise, understand, and accept challenging feelings and situations as opposed to actively trying to eliminate or change them. Acceptance and commitment therapy allow individuals to open-up to unpleasant feelings they may be experiencing, learn to not avoid situations or circumstances that may elicit these feelings, and to learn not to overreact to them.

Medical treatments

Medical health professionals (e.g., General Practitioners) may prescribe an anxiolytic (anti-anxiety medication) to help treat the anxiety symptoms related to paruresis. The use of anxiolytic medication alongside psychological therapy is best discussed with your treating doctor (see below for further information).

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a type of medication prescribed to address anxiety symptoms. SSRIs work by reducing the reabsorption of serotonin by nerve cells, which in turn leads to increased levels of serotonin within the brain. Serotonin is a naturally occurring neurotransmitter/chemical within the brain that is involved in the regulation of a variety of functions such as mood. In anxiety disorders, serotonin is in a state of imbalance. Through the stabilisation of serotonin levels, SSRIs may assist in decreasing anxiety symptoms associated with paruresis. Your treating doctor may prescribe SSRIs under a variety of names such as paroxetine, fluoxetine, escitalopram, citalopram, and sertraline.

SUMMARY OF PARURESIS

Paruresis is a psychological condition characterised by a difficulty or inability to initiate or sustain urination due to overwhelming fear of perceived scrutiny. Paruresis typically occurs in busy public restrooms but can occur in private restrooms in severe cases. The prevalence of paruresis has been reported to range between 2.8 and 16.4%, with males typically being affected in greater numbers than females. Paruresis is classified as a form of social anxiety disorder as both conditions share similar features. The most recent model of paruresis argues that psychological processes such as fear of negative and positive evaluation, along with dysfunctional attitudes and concerns of social reprisals contribute to paruresis symptoms. Individuals with suspected paruresis should be examined by a medical doctor to ensure that their symptoms are not due to a medical cause. A range of psychological and medical treatments are available for individuals with paruresis.