Shy Bladder Syndrome (Paruresis)

What is shy bladder syndrome?

Shy bladder syndrome (paruresis) is a type of social anxiety disorder. People who have this disorder are unable to or have severe difficulty urinating (peeing) when they’re away from home. No matter how urgently they have to go, they have a lot of trouble peeing in a bathroom that isn’t their own. Healthcare providers also call this disorder:

• Avoidant paruresis.
• Bashful bladder syndrome (BBS) or bashful kidneys.
• Pee phobia.
• Psychogenic urinary retention.
• Urophobia.

People with this condition are physically able to pee, but their anxiety prevents them from being able to go in certain situations or places. This often includes public restrooms or someone else’s bathroom. The muscles in their bladder and urinary tract tense up and can’t relax to let urine flow.

Untreated, severe paruresis can have a major impact on quality of life. It can cause people to avoid traveling, getting together with friends, visiting public places or going to work. Healthcare providers treat this disorder with therapy and hypnosis. Some people use a catheter (a long, thin tube) to empty their bladder when they aren’t at home.

Who might get paruresis?

Healthcare providers believe that you may be more likely to develop paruresis if your parents had the disorder. People who have other types of anxiety disorders are also at a higher risk of developing shy bladder syndrome. This means you’re more likely to have paruresis if you have:

• Generalized anxiety disorder (GAD).
• History of mental illness.
• Obsessive-compulsive disorder (OCD).
• Panic attacks or panic disorder.

Anxiety, fear or intense emotions can make paruresis worse. Shy bladder syndrome often occurs along with the inability to defecate (poop) in public. Healthcare providers call this condition parcopresis.

How common is paruresis?

Healthcare providers aren’t sure how many people have this disorder. But it is common. Some studies suggest that up to 25% of people in the United States have some degree of paruresis. It affects people of all genders and ages, including children.

What causes shy bladder?

Healthcare providers don’t know exactly what causes this disorder, but it can develop as part of post-traumatic stress disorder (PTSD). Some people with paruresis had an uncomfortable or traumatic experience in the past, such as sexual harassment or abuse in a public restroom. Someone might have bullied or teased them while they were peeing.

People who are already self-conscious, embarrassed or shy may feel extremely uncomfortable peeing around others. They may worry about the way they smell or the sounds they make while peeing.

Feeling concerned or getting emotional can make it even more difficult to start the flow of urine. These concerns can worsen your anxiety and cause you to tense up. Some situations are triggering to people with shy bladder. They may include:

• Being around other people, whether familiar or unfamiliar, while trying to pee.
• Being too close to others and worrying that others can hear, see or smell them.
• Feeling pressured or rushed.
• Not having enough privacy to pee (for example, if there isn’t a stall or partition in a public restroom or if someone is waiting just outside the door).
• Trying to force yourself to pee, which can worsen tension and make the problem worse.

What are the symptoms of paruresis?

Shy bladder syndrome symptoms range from mild to severe. Most often, symptoms worsen over time. Some people may only be able to go when they’re at home by themselves.

People with mild paruresis may only be able to go in certain situations. For example, men might have no trouble peeing in a private stall but can’t pee in a urinal. Or they may have a delay in starting the stream of urine when they’re in a public restroom.

People who have this disorder might:

• Avoid drinking fluids right before leaving home and while they’re away from home.
• Have symptoms of a panic attack, such as dizziness, dry mouth, sweating (hyperhidrosis) or a fast heart rate.
• Look for a bathroom where they can be alone, even if they have to walk a long way to find one.
• Need to try certain tricks to help them pee, like thinking about running water or turning on the faucet to help them start the flow.
• Stop traveling, going to work or attending social events.
• Develop agoraphobia (in severe cases) and avoid leaving their house at all. This can damage relationships and make it difficult to hold down a job.

How is paruresis diagnosed?

Usually, your healthcare provider can diagnose paruresis after reviewing your symptoms. Your healthcare provider may suspect paruresis if you’re able to use the bathroom at home, but you have problems peeing when you’re away from your own toilet. To diagnose paruresis, your healthcare provider might refer you to a psychologist or a urologist (a healthcare provider who specializes in the urinary tract).

Your healthcare provider will rule out medical conditions that might be causing urinary retention (the inability to empty your bladder). Infections, nerve damage or a blockage in your urinary system (such as a ureteral obstruction) can make it difficult to pee, too. To check for these conditions, your healthcare provider will do a physical exam. They may also order a urine test (urinalysis), complete blood count (CBC) or an ultrasound to look at your bladder.

Some medications can make peeing difficult or impossible. Tell your healthcare provider about any medications you’re taking so they can determine if one of them might be causing your symptoms.

How do healthcare providers treat shy bladder syndrome?

Talk to your healthcare provider about the most appropriate treatment for you. Treatments include:

• Cognitive behavior therapy (CBT), a treatment that helps you change your behaviors by viewing anxiety from another perspective.
• Graduated exposure therapy, which helps you practice peeing in a controlled environment. Working with a partner (such as a therapist, friend or family member), you attempt to pee in bathrooms that aren’t your own. Over several sessions a week, you gradually increase your exposure to public toilets until you’re able to go when and where you need to.
• Hypnotherapy, which includes guided relaxation exercises while your mind is in a calm state. This allows you to rethink your anxiety and teach yourself how to pee in public restrooms.
• Medications to lower anxiety.
• Meditation and breathing exercises to help you control anxiety and relax your urinary tract.
• Psychotherapy, or talk therapy, to treat mental health issues that might be causing shy bladder.
• Self-catheterization (clean intermittent catheterization), which uses a tube to empty your bladder when you’re away from home.

How can I prevent shy bladder syndrome?

There isn’t a way to prevent paruresis. If you have other types of anxiety, talk to your healthcare provider about therapy or medications that can help you gain more control over your feelings.

What is the outlook for people with paruresis?

Most people find relief from paruresis after therapy and other treatments. Some studies show that around 80% of people with this disorder are able to pee in public after undergoing CBT and graduated exposure therapy. Hypnotherapy, psychotherapy and CBT are also very effective at helping people understand their anxiety and change their behaviors.

Untreated, shy bladder syndrome can lead to social problems and trouble at work. People who have to give urine samples for drug testing may need to make special arrangements with their employer. If you’re unable to provide a urine sample for a drug test, you may be able to give a sample of your blood, hair or saliva (spit) instead.

Paruresis can cause you to hold pee in your bladder, which can lead to serious health problems. These include:

• Urinary tract infections (UTIs).
• Damage to muscles in the bladder, which can lead to urinary incontinence.
• Burst bladder (in severe cases).

When should I see my healthcare provider about paruresis?

It’s important to get an examination to see if you have a health condition that’s preventing you from being able to pee. If you’ve ruled out these health conditions and having a shy bladder affects your daily life, talk to your healthcare provider. Make an appointment if this disorder causes you to miss work, avoid outings or stay home when you’d rather go out.

Get immediate medical help if you have to go, but you aren’t able to pee (either at home or in public) for more than a few hours. It’s dangerous to hold in your pee for too long. After several hours of holding it in, the muscles in your bladder may not be able to relax to let urine flow at all — even when you’re at your home toilet.

A note from Cleveland Clinic

Shy bladder syndrome (paruresis) can significantly impact your quality of life. If you’re going out of your way to avoid using a bathroom that’s not your own, talk to your healthcare provider. Untreated, symptoms of this anxiety disorder can worsen over time. Holding in pee for long periods can lead to serious health problems, including UTIs and bladder problems. Be open and honest with your healthcare provider about your symptoms and when they occur. Therapy can help you enjoy outings, traveling and social events with greater comfort.