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Medical News Today: Shy bladder: Causes and treatments

Public restroom with clean toilet cubicles.
A shy bladder is when a person feels unable to urinate when other people may be nearby.
People with shy bladder syndrome, or paruresis, have a hard time urinating with other people around.

The condition is caused by anxiety rather than a physical blockage.

What is shy bladder?

Technically, paruresis refers to difficult or abnormal urination.

Shy bladder syndrome (SBS) results from fear or anxiety of urinating around others or in public restrooms. People with SBS can urinate freely alone at home but not in public settings.

SBS is considered a type of phobia, or excessive fear of a particular thing, activity, or situation. The condition is also considered a social anxiety disorder.

According to the International Paruresis Center, an estimated 7 percent of people in the United States experience SBS to some extent. It is considered one of the most common types of social phobia or anxiety.

SBS is also known as avoidance or avoidant paruresis, or psychogenic urinary retention.

Causes

Woman needs to urinate.
There are many possible causes for bladder shyness, including anxiety and self-consciousness, as well as concern about hygeine in public restrooms.

SBS is typically caused by anxiety surrounding the idea of urinating in a setting where other people may be able to hear or see.

The bladder relies on a signal from the brain to relax and empty itself. The anxious feelings related to SBS cause the brain to send a signal to the bladder to contract rather than release.

According to the Urology Care Foundation, SBS may develop at any point in a person’s life or may be passed from parents to children. In some cases, urination may be impaired by physical conditions that develop in response to mental and emotional symptoms.

Although the condition can develop at any age, many people with SBS develop the phobia after a negative experience in late childhood or adolescence. In cases of child abuse, a daycare employee or teacher may be the first to note the condition.

The first negative experience is often enough to make a person anxious about the next time they will have to urinate around others.

Common causes of SBS include:

  • concern that others may hear urination and judge the amount, consistency, or duration of urine flow (especially for men)
  • worry that being able to hear urination is uncomfortable or awkward
  • concern that others may notice and judge how often urination occurs, especially for those with overactive bladders, medications, or kidney conditions that make urination more frequent
  • negative experiences in public restrooms, such as harassment
  • child abuse focused around urinating, such as excessive discipline during potty training
  • sexual assault or abuse
  • being pressured to urinate, especially common among groups of boys
  • being ridiculed or made fun of for urinating, often for having an accident
  • fear or anxiety about the sanitary or hygiene level of public toilets or restrooms

Before even entering another public bathroom, people with SBS may start to imagine the worst-case scenario. By the time they enter the bathroom, the anxiety and anticipation can be so intense that urination becomes difficult.

Possible complications

Depending on the severity of the condition, SBS can make everyday activities difficult. 

People with mild or minor anxiety may take a little longer to urinate or simply wait to be alone in the restroom.

Men may choose the privacy of a stall over urinals. Some people with SBS think about running water or may turn on the tap to stimulate the urge to urinate.

People with more moderate anxiety may avoid public washrooms altogether except for emergencies. People with severe anxiety may be unable to urinate anywhere except their home.

Some of the more common complications associated with the condition include:

  • feeling anxious, sweaty, or faint when in public bathrooms or urinating with others near by
  • being unable to spend more than a few hours away from home at a time
  • being unable to travel on airplanes, buses, or trains where public restroom use is unavoidable
  • becoming entirely house-bound
  • being unable to perform medical tests that require urination
  • being unable to perform urine-based drug tests, especially problematic if routine testing is required or necessary for employment
  • having frequent urinary tract infections
  • dehydration from avoiding fluids
  • reduced or limited social life
  • relationship conflict
  • kidney infection and disease

Diagnosis

Discussing the topic may be uncomfortable, but most people need outside help to reduce symptoms and resolve the condition.

To rule out medical or physical causes, a doctor should be consulted first. Conditions like prostatitis, or inflammation of the prostate, can also make urination difficult.

In most cases, the only true way to treat SBS is to address the underlying phobia or anxiety. This typically means attending therapy sessions with a trained mental health professional.

Treatment and outlook

Cognitive behavioral therapy
Cognitive behavioral therapy has a high success rate and may help treat bladder shyness.

Cognitive behavioral therapy (CBT) techniques or plans may help lessen or resolve symptoms. According to the Urology Care Foundation, CBT is effective in about 85 percent of cases.

The goal of CBT is to break the association between urinating and anxiety. Most plans begin by identifying the cause of the fear then retraining the brain to associate the cause with positive or neutral feelings.

It is also important to focus on urination as a necessary, unavoidable bodily function instead of a performance or competition. There is no such thing as an ideal flow, volume, or sound when it comes to urination.

Therapy plans will also typically involve gradual exposure therapy, where exposure to the dreaded setting or activity is slowly increased. Where this process starts, and how quickly it progresses, depends on the individual.

For mild cases of SBS, a good starting point may be entering a public bathroom and going into the stall for 1 minute before leaving.

Individuals with more severe symptoms may need to begin at home. A good at home exercise is to mentally repeat a string of positive words or thoughts while urinating at home in privacy.

Once the individual can complete the initial exercise without difficulty, they can slowly increase exposure until their anxiety while urinating in public settings is substantially reduced.

In cases where the condition severely impacts a person’s quality of life, a urologist may recommend intermittent self-catheterization or clean intermittent catheterization.

Catheterization involves the insertion of a small plastic tube into the urethra, the genital structure that allows urine to exit the body, to let the bladder drain.

For more detailed information on the purpose and use of catheters, The National Association for Continence has instructional videos available.

A few medications or additional therapies methods have been suggested and used with mixed success. Potential, but unproven, treatment options include:

  • anti-anxiety or antidepressant medication
  • botulinum toxin injection in the muscle that controls bladder contraction
  • hypnotherapy
  • relaxation techniques
  • group or joint therapy sessions

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