Most people on more than one occasion have felt the need to urinate in contexts and situations far from their home.

In a bar or restaurant, in a shopping centre, in a hospital, at work, during a trip… in all these places we have a toilet where we can urinate more or less comfortably, and we usually go to them without any problem other than the fact of locating it or that it is not already occupied.

However, some people are unable to use a public toilet , not being able to urinate in the presence of others or in places where there is a risk that others may know they are doing so. These people suffer from paruresis, also called shy bladder syndrome .

Conceptualizing paruresis

We understand as paruresis or shy bladder syndrome a psychological disorder characterized by the impossibility or high difficulty to use public toilets , not being able to excrete urine in that situation.

Paruresis has sometimes been conceptualized as a type of social phobia because the inability to urinate is caused by the observation of other people or by the idea of being easily observed. As in social phobia, such a situation, in which they can be judged and evaluated by others, generates a high level of anxiety and can mean a real alteration in the person’s life leading to the avoidance of certain stimuli and situations. Some strategies used by those affected by paruresis are not to drink liquids outside the home or to retain them until they get home, although the severity of the condition can vary greatly from case to case.

In this way, the shy bladder syndrome can cause from a slight delay in the process of urinating in the mildest cases to total avoidance, with the affected person not wanting to leave the vicinity of their home and even isolating themselves and avoiding contact with partners and relatives so that they cannot hear them urinate, in the most serious cases.

Possible causes

Although paruresis is a not very well known phenomenon, the research carried out shows that the causes of this syndrome are predominantly of psychogenic origin . In other words, the reason for this disorder is of an acquired and mental type.

Experts who have studied shy bladder syndrome or paruresis indicate that multiple factors can produce or maintain this type of problem.

One of the main causes is the presence of a child trauma linked to a situation produced in public baths. For example, it has been detected that in a large number of cases individuals with paruresis suffered bullying in their childhood, being harassed, judged and abused. For this and other reasons (e.g. having a very critical family) the subjects tend to have a high level of insecurity, presenting in some cases inferiority complexes that are triggered in a situation of exposure, being in these people the use of the bathroom in the presence of others.

It has also been observed that people with paruresis have a high sensitivity to criticism , fearing to be seen as unsuitable and also tend to have a low level of assertiveness. Doubts and fears about the anatomy and characteristics of the genitals themselves are also observed very frequently, with these subjects fearing that they will be laughed at or valued.

Gender differences

While documented cases reflect that it is more common in males, there are also a large number of females with this disorder.

Data from some studies reflect that there is some differentiation in the type of aversion that occurs in men and women. Specifically, it seems that the female sex is more disturbed by the idea of hearing or being heard by other people around her , while in men it is the idea of being seen urinating by other people.

This has a logical explanation if we think about how the public toilets are structured, placing the male urinals in battery, so that the urination of other men is visible, while in the case of women the cubicles are usually separated by a wall or screen can not usually be seen by others but heard.

Treatment for shy bladder

If you have difficulty in urinating, the first thing you should do is go to a doctor’s office to assess the possibility of a medical problem that could cause the problem. Once the medical etiology has been ruled out, and the case analyzed, the diagnosis of paruresis.

Cognitive-behavioral treatment has shown a good level of effectiveness in shy bladder syndrome, treating on the one hand cognitive problems such as the belief that it will be evaluated and tolerance to criticism, as well as the patient’s behavior.

Taking into account that it has been considered a subtype of phobia, the psychological treatment of choice at the behavioural level would be the gradual exposure to the feared stimulus . This graduation will take into account that over time the patient will have to urinate in toilets that make it increasingly difficult for him/her to do so.

For example, the exposure may begin at the patient’s home, first completely alone and then have someone else wait behind the door. Once the anxiety has subsided or if there has been no anxiety to this degree, it is moved to other bathrooms, for example in the homes of family or friends, and then urination will be carried out in uncrowded public bathrooms (such as those in a library or cinema) until it reaches busy places such as the bathrooms in a discotheque or during a celebration. It is important that the exposure is very gradual, moving to the next level only after the anxiety has decreased by at least half.

These treatments are very effective , although it must be taken into account that what is being treated is the current problem, that is, the symptoms that the patient has today. It would also be very useful to incorporate other types of treatments that would allow us to work on the reason for the appearance of paruresis and the sensations it causes at a deep level, in order to prevent this and other problems.

Bibliographic references:

  • Hammelstein, P.; Soifer, S. (2006). “Is “shy bladder syndrome” (paruresis) correctly classified as social phobia?” Journal of anxiety disorders 20 (3): 296-311.
  • Prunas, A. (2013). Shy bladder syndrome. Riv. Psichiatr. 48 (4): 345-53.
  • Rees, B. & Leach, D. (1975) The social inhibition of micturition (paruresis): Sex similarities & differences. Journal of the American College Health Association, Vol 23(3), 203-205.
  • Williams, G.W. & Degenhardt, E.T. (1954). Paruresis: A survey of a disorder of micturition. The Journal of General Psychology, 51, 19-29. Department of Psychology, Rutgers University.