Shy Bladder Syndrome (Paruresis)

Shy bladder syndrome (paruresis) is a type of social anxiety disorder that makes it difficult or impossible to pee away from home. No matter how urgently you have to go, you have a lot of trouble peeing in a bathroom that isn’t your own.

If you have paruresis (pronounced “par-er-REE-ses”), you’re still physically able to pee. But anxiety prevents you from being able to go in certain situations or places. This often includes public restrooms or a bathroom in someone else’s home. The muscles in your urinary system and bladder tense up. When these muscles can’t relax, pee can’t flow.

Experts aren’t sure how common paruresis is. This may be because many who experience it don’t seek help. One study estimates that it may affect around 3 to 16 out of every 100 people.

There isn’t a way to prevent paruresis. Without treatment, it can have a major impact on your life. You may avoid traveling, meeting with friends, visiting public places, or going to work or school. But therapy and medications can help you relax and empty your bladder when you aren’t home.

Other names for paruresis include:

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

What are the symptoms of paruresis?

The main symptom is anxiety that prevents you from peeing comfortably when you’re outside of your home. In public, you may have urinary hesitancy symptoms, like:

• Straining or pushing to pee
• Slow or weak pee stream
• Dribbling

Symptoms range from mild to severe. They tend to worsen over time. Some people may only be able to pee when they’re at home by themselves.

If you have mild paruresis, you may only be able to go in certain situations. For example, if you’re male, you may have no problem using a public restroom if a private stall is available. But you can’t pee in a urinal. Or it may take you a while to start peeing when you’re in a public restroom.

If you have shy bladder syndrome, you also might:

• Avoid drinking fluids right before leaving home and while you’re away from home
• Have symptoms of a panic attack, including dizziness, dry mouth, sweating a lot or a fast heart rate
• Look for a restroom where you can be alone, even if you have to walk a long way to find one
• Wait until you’re alone in a restroom before you try to go
• Need to use certain tricks to help you pee, like thinking about running water or turning on a faucet
• Stop traveling, going to work or attending social events

In severe cases, you may develop a fear of being overwhelmed or helpless (agoraphobia). This can cause you to avoid leaving your house at all. It can affect your relationships and make it challenging to have a job that requires you to be away from home.

What causes it?

Experts aren’t exactly sure what causes paruresis. But it can develop as part of post-traumatic stress disorder (PTSD). Some people with shy bladder syndrome had an uncomfortable or traumatic experience in a public bathroom in the past. This may include bullying or teasing while peeing. It may also include sexual harassment or abuse.

If you’re shy, self-conscious or if you embarrass easily, you may feel uncomfortable peeing around others. This can make it harder to start peeing, worsen anxiety and cause your body to tense up. Situations that may be triggering include:

• Being around others, including strangers or people you know, while trying to pee
• Being too close to others and worrying they can hear, see or smell you
• Feeling pressured or rushed
• Not having enough privacy to pee, including no available stalls, no dividers (partitions) between urinals or knowing someone is waiting outside the door
• Trying to force yourself to pee, which can increase tension and make peeing more challenging

Risk factors

Paruresis can affect anybody at any age, including children. But males tend to experience it more than females. Experts also believe you may be more likely to have paruresis if your biological parents have it.

You may also have a higher risk of developing shy bladder syndrome if you have other types of anxiety disorders. These include:

• Generalized anxiety disorder
• Obsessive-compulsive disorder
• Panic attacks

Shy bladder syndrome often occurs along with trouble pooping away from home (parcopresis).

Complications

Without treatment, paruresis can lead to social problems and trouble at work or school. For example, if you need to provide a pee sample for drug testing, you may need to make special arrangements. If you can’t provide a sample, ask if you can give a blood, hair or spit (saliva) sample.

Holding pee in your bladder for long periods can also lead to other health issues. These include UTIs and damage to your bladder muscles. Bladder muscle damage can lead to urinary incontinence. In severe cases, your bladder can burst. Serious problems can develop if pee leaks into your body.

How doctors diagnose paruresis

In most cases, your healthcare provider can diagnose it after reviewing your health history and symptoms. Some medications can make peeing more difficult. Tell them about any prescription or over-the-counter medications you’re taking. They may also suspect shy bladder syndrome if you’re able to use the bathroom at home, but have problems if you’re in public or at someone else’s home.

Other conditions can prevent you from emptying your bladder. These include urinary tract infections (UTIs), nerve damage or a blockage in your urinary system. They may recommend additional tests to help rule out these conditions. Tests may include:

• Physical exam
• Pee test (urinalysis) and/or blood tests to look for signs of an infection
• Abdominal ultrasound to look at your bladder and other organs in your urinary system

To make an official paruresis diagnosis, your healthcare provider may refer you to a urologist or a mental health professional (therapist, psychologist or psychiatrist).

How do I pee when I have a shy bladder?

There are many different treatment options available. Your healthcare provider will talk to you about:

• Psychotherapy (talk therapy) to identify and treat any mental health conditions
• Cognitive behavior therapy (CBT) to create a structured, goal-oriented plan to help change some behaviors
• Graduated exposure therapy to help you practice in controlled environments, so you gradually get more comfortable peeing in bathrooms that aren’t your own
• Support groups to safely share your feelings and experiences with others who have shy bladder syndrome
• Hypnosis (hypnotherapy) to help calm your mind and teach you how to pee in public restrooms
• Meditation and breathing exercises to help control your anxiety and relax the muscles in your urinary tract
• Mental distractions, like doing a math problem, reciting book passages or holding your breath
• Self-catheterization to drain your bladder

They may also recommend medications to help lower your anxiety or relax your bladder muscles. These may include:

• Benzodiazepines
• Antidepressants
• Alpha-blockers
• Bladder-stimulating medications

When should I see my healthcare provider?

Talk to your healthcare provider if paruresis affects your daily life. This may include missing school or work, avoiding outings or staying home even if you really want to go out.

Get medical help immediately if you have to pee but can’t (either at home or in public) for more than a few hours. It’s dangerous to hold your pee for too long. After several hours, your bladder muscles may not be able to relax, even when you’re using your own bathroom.

Does paruresis ever go away?

Yes, you can manage it. But it often requires treatment. Cognitive behavioral therapy and graduated exposure therapy have good success rates. Hypnosis, talk therapy and CBT can also help people understand their anxiety and change their behavior.