Paruresis (Shy bladder)

Individuals with paruresis are likely to experience anxious thoughts about using the restroom, as well as difficulties with urinating. These symptoms are generally worse in public settings (e.g., shopping centres, restaurants), where the individual perceives that others can hear or see him/her using the restroom.

Individuals with paruresis tend to experience an increase in symptoms when there are more people present and in closer proximity (e.g., a busy public bathroom with a queue of people waiting to use the facilities). Level of anxiety may also depend on the privacy of the facilities, for example, using a urinal may cause more anxiety than when using a cubicle. For some individuals, anxiety relating to using the restroom while at home can occur when others such as family and/or friends are present.

Symptoms of paruresis can include:

• A pronounced difficulty or inability to urinate in public restrooms. In severe cases, a difficulty or inability to urinate at home when family and/or friends are present.
• Physical symptoms consistent with anxiety such as a rapid or racing heartbeat, trembling, muscle tension, excessive sweating, nausea, and blushing.
• Avoidance behaviours such as avoiding using restrooms in public, limiting and/or avoiding public transport.
• Safety behaviours such as reducing fluid intake in order to avoid using a public restroom.
• Seeking public restrooms that offer greater privacy.
• For males needing to urinate – choosing to use cubicles instead of available urinals.
• Avoiding holidays and/or social activities such as parties, dating, sporting events, and other occasions where using a restroom may cause anxiety.

Paruresis is associated with feelings of shame, embarrassment and problems across multiple domains of life, including relationships, social activities, and employment. Anxiety around restroom usage can influence the type of work environment that an individual is comfortable in, andmay affect whether they are willing to travel for work,especially in the case of airplane travel. Paruresis can also have an adverse impact upon individuals where their role requires drug testing. While paruresis can have a significant adverse impact on psychosocial functioning and associated quality of life, the majority of individuals living with paruresis do not seek treatment.

The onset of paruresis is often in adolescence.

The prevalence of paruresis has been noted to range between 2.8 and 16.4% of the population, with males typically affected by paruresis more than females.

Prevalence variation between genders may be due to several reasons:

• Genitourinary differences between males and females where males tend to develop urinary retention (difficulties with urination) as they age due to the prostate gradually increasing in size.
• Differing layouts between male and female restrooms. In male restrooms, men typically urinate in standing urinals whereas in female restrooms, females urinate in closed cubicles that provide greater physical privacy and personal space.

At this time there is no validated diagnostic criteria published for paruresis. Diagnosis of paruresisis based upon ruling out physical reasons for difficulties urinating and the presence of psychological symptoms associated with difficulties urinating in public restrooms. In some individuals, paruresismay also be present along with physical reasons for difficulties urinating;however the psychological symptoms must be clear and significant contributors to the reported difficulties urinating in public restrooms. 

There are a variety of factors that may contribute to paruresis. The following is a summary of factors that have been associated with the development of paruresis:

Past experience or trauma

Some individuals report that the onset of their paruresis was associated with a difficult or traumatic experience, such as being bullied or teased in a public restroom, being rushed by another personor being unable to produce a urine sample for a medical or drug test.

Psychological difficulties

Paruresis is associated with several other psychological conditions, including social anxiety disorder, obsessive compulsive disorder,and depression.Anxiety, regardless of its cause, can affect the ability to urinate. Through a series of physiological processes, feelings of anxiety and fear can impact upon the function of the detrusor muscle and the external urethral sphincter, making it more difficult to urinate. In addition, failure to urinate, and concerns about failing in the future, may further increase anxiety. Click HERE for further details.

Family history

Paruresis may be learnt in childhood from the behaviour of close family members. For example, if a father experiences anxiety around using public restrooms, the child may interpret that restrooms are not a safe place and take on his father’s fears.