Paruresis is an embarrassing condition which severely limits the quality of life of the person concerned. It is best defined as the inability to urinate unless in a completely private setting. The affected person can sometimes pass urine only at home and when there are no guests. It is thought to be very common, a phobic condition ranking second to the fear of public speaking.
Paruresis may be due to some embarrassing incident connected with difficulty in urination, be it teasing by schoolmates in the public urinal, or abuse as a child. This then causes the person to anticipate the failure to void in a public setting, and somehow the fear becomes self-fulfilling.
Paruresis affects both women and men. It is also termed psychogenic urinary retention, since the urinary sphincter responds to stress and fear by constricting instead of relaxing. There is mounting emotional and mental stress whenever the need arises to urinate without absolute privacy being possible.
It is also called ‘shy bladder syndrome’, since the people affected are characteristically shy and sensitive to others’ disapproval or judgment. It is a form of performance anxiety which turns into an active phobia. This has been estimated to affect anywhere between 1-25% of people in the USA. It has a familial tendency as well.
The symptoms are characteristic. In moderate to severe cases, they may include a compulsion to ensure total privacy during the act of urination. Thus the affected person cannot tolerate even the possibility of others hearing the sound of urine hitting the urinal or the water in the toilet.
The person has a morbid conviction that he is unable to initiate urination in front of others. This progresses to the point that urination is possible only at home and when there are no guests. In order to avoid the possibility of having to go to a toilet outside the home or visit a public urinal, the affected person will refuse to drink fluids if he has to go out shortly. He may reject all invitations to social events, and refuse to take trips.
In milder cases, the affected person will not be able to start peeing when in proximity to someone else, as happens at public urinals. He will search for a vacant restroom before trusting himself to urinate.
Diagnosis and treatment
The top priority in this case is to make sure that there is no physical cause for urinary retention, such as abnormal bladder muscle activity, a tight urinary sphincter, prostate enlargement, a urinary infection or a urinary stone. Once the diagnosis is made, the urologist can offer reassurance that the condition is neither unique nor untreatable.
Further management most often requires anxiety treatment using cognitive and behavioral modification therapy techniques. A specialist in anxiety disorders or phobias will be able to guide the person’s recovery by using techniques such as graduated exposure. This will habituate the person to the use of public urinals. This is successful in 80% of affected people.
Clean self-catheterization may help the person with the immediate need to drain the bladder when away from home. This technique can also improve the quality of life greatly, since it avoids the need to initiate urination inside a public urinal or in any toilet outside one’s own house.
Other modes of treatment include hypnosis, alpha-blockers to relax the urethral sphincter, botox injections to keep the sphincter looser than usual, and even prostate removal.
These have not proved successful with any degree of uniformity. Certain anxiety-reducing drugs (SSRIs) have been reported to be successful as an adjunct to therapy. They help allay the mental distress to the point that the person is able to respond to cognitive and graduated exposure therapy.