People suffering from paruresis find it difficult and sometimes impossible to urinate in public restrooms. Nearly 3 percent of all men are affected, but they rarely consult a professional because of the taboo nature of the problem. This is unfortunate in that there are effective methods to combat paruresis.
What is paruresis?
Paruresis is a micturition disorder caused by psychological factors. Micturition is also colloquially referred to as “urination.” Affected individuals have inhibitions about emptying their bladder in public restrooms. Either they need a certain amount of time to get to this point or they have to forgo relief and leave the toilet again. Inhibition is particularly caused by the presence of other men. Different gradations and degrees of severity are observable in what is also called shy bladder. Some of the affected men prefer to go to a cubicle rather than a urinal because here they are away from the possible gaze of other toilet users. Some are able to relax better when sitting down. In severe cases, even these measures no longer help and urination is only possible at home. The consequence is a massive reduction in quality of life.
Causes
The cause lies in a formative situation experienced by those affected – usually during puberty – in which they have felt fear, shame and stress. They have felt watched while urinating or have been laughed at for not being able to urinate immediately. This experience can contribute to the development of what is known as “anticipatory anxiety”: fear of “failing” again the next time they visit a public restroom facility sets in. Thus, a cycle is set in motion that can hardly be corrected. In addition, it happens that psychological stress without a triggering experience can cause the problem. It is not possible to relax and bladder emptying is blocked. In men, the internal and external sphincter muscles close the urethra and usually ensure that the bladder does not empty against one’s will. However, when going to the toilet, nervousness and stress can prevent the sphincter muscles from relaxing and thus the bladder from emptying.
Symptoms, complaints and signs
About one-third of all men occasionally face the problem of not being able to urinate, but those who suffer from paruresis have multiple sufferings: In situations in which they absolutely must urinate (before starting a long flight, during a bus ride), they succeed with particular difficulty. The severe physical discomfort is compounded by psychological irritation. This is aggravated by the fact that other people cannot understand the problem and smile at it. Those affected feel misunderstood and have the feeling that something is wrong with them. This increases the tension. Often those people suffer from paruresis who have a tendency towards perfectionism and self-observation. They also attach great importance to what other people think about them, but this quickly makes them feel observed. And the feeling of being watched plays a crucial role in the shy bladder.
Diagnosis and course of the disease
To make a diagnosis, it is first necessary for a specialist to rule out possible physical causes (enlarged prostate, narrowing of the urethra). Various psychotropic drugs may also be responsible for urinary retention. The taboo nature of the disease usually also shapes its course: Affected persons try to hide it from their fellow men, to come to terms with it and to integrate it into their lives. They show pronounced avoidance behavior, which makes their professional activities, leisure time and relationship life more difficult. Not infrequently, the difficulties lead to social withdrawal and depression.
Complications
Paruresis in varying degrees is actually not that rare, nor is it usually a serious condition. It is also not the effects of urinary behavior in public toilets that lead to complications. After all, the urinary behavior in shy bladder only affects public toilets, where the affected person feels observed by others. At home, emptying the bladder works without any problems. However, the effect on the psychological development of the affected person can be problematic with paruresis.Most often, paruresis develops during puberty, when male adolescents place special emphasis on the body and masculine behavior. Paruresis can be triggered by trauma. Or it may be a fear of not being able to perform the standing pee, which is considered masculine behavior, in front of the gaze of others and therefore being ridiculed. The male adolescent affected by paruresis avoids using public toilets out of this fear, thinking that others will judge him as unmanly or even abnormal. This often leads to a dangerous inferiority complex, which can overshadow the whole life. In severe cases, the affected person becomes completely socially isolated, only to be able to always go to the bathroom at home. If left untreated, depression and even suicidal tendencies can develop as late consequences.
When should one go to the doctor?
Individuals who have a great fear of using public restrooms should discuss this problem with a psychologist or psychotherapist. If paruresis is present, treatment is generally recommended, because the phobia can have a negative impact on the quality of life if, for example, the person is unable to go to the toilet on an airplane or bus. A visit to the doctor is necessary if the avoidance behavior leads to noticeable limitations in everyday life. Anyone who, because of the phobia, looks for a job near their own home or avoids longer trips may have paruresis that requires treatment. People who suffer from the described fears should first consult their family doctor. He or she can make an initial tentative diagnosis and, if necessary, consult a specialist. The condition is worked through in the context of behavioral or talk therapy and can thus be effectively treated. In the case of severe phobias, inpatient treatment in a specialist center for anxiety disorders is necessary.
Treatment and therapy
Avoidance behavior is a clear sign of the disease, and this is where treatment comes in. As part of behavioral therapy, those affected face the stressful and anxiety-provoking situations under the guidance of an expert. An attempt is made to gently increase the level of difficulty: At the beginning, there is a visit to an empty public toilet and urinating while sitting in a cubicle; the end of a successful therapy consists of urinating at a urinal in a busy public toilet. The goal is elimination of fear of failure and maturation of awareness that it does not matter what other restroom visitors (may) think. Another tool – often used to accompany behavioral therapy – is relaxation exercises that can be done at home. These include progressive muscle relaxation according to Edmund Jacobson or pelvic floor training according to Arnold H. Kegel. These help to train and target the contraction and relaxation of the sphincter muscles involved in emptying the bladder. The chances of success with treatment are very good and should encourage sufferers to overcome their shame and confide in a professional.
Outlook and prognosis
In principle, paruresis is curable. The mental disorder should be treated in the early stages for a good prognosis. The more severe the symptoms are and the longer the disorder has already existed, the more protracted the recovery process normally is. Without therapy, the affected person rarely succeeds in recovery. Rather, an increase in anxiety is to be expected and further psychological disorders may develop. The prognosis is worse in these cases, as the development of anxiety or phobic behavioral traits can spread to other areas. Relief of the symptoms occurs exclusively if the cooperation of the affected person is present. Otherwise, doctors and therapists can only achieve limited success. An improvement of the health situation is achieved by initiating changes through behavioral training and cognitive work. In most cases, working through the cause is not necessary. Rather, the focus of treatment is on learning to urinate in public places. At the same time, the general feeling of anxiety and the resulting physical discomfort are gradually reduced.For a successful prognosis, sufficient patience is required in addition to a rapid start of therapy and a willingness to alleviate symptoms. Improvements are often achieved after a few weeks or months. However, some patients require years to achieve freedom from symptoms.
Prevention
Because in most cases a traumatic event has triggered paruresis, prevention is difficult. The widespread belief that a man is a “real” man only if he empties his bladder while standing up adds to the suffering. Stereotypes such as these lead to the insecurity and endangerment of unstable people who are concerned about the opinions of their fellow men. The best prevention is to develop more self-confidence and not to give importance to the circulating views about what a “real” man should master.
Aftercare
In most cases, the person affected by paruresis has very few or limited measures or options for aftercare. Therefore, the affected person should see a doctor very early in this disease, so that it does not lead to complications or other complaints in the further course. The earlier a doctor is consulted, the better the further course of the disease usually is. Therefore, a doctor should be consulted already at the first signs and symptoms. Paruresis can be alleviated by various therapies and relaxation exercises. However, a complete cure cannot always be achieved, so that those affected must continue to avoid public toilets in their lives. In many cases, the support and help of the patient’s own family is very important in alleviating the symptoms. Further measures of an aftercare are thus not available to the affected person in case of paruresis. However, the disease has no particular effect on the health of the affected person, so that paruresis does not reduce the life expectancy of the affected person. In this case, the affected person can also try to urinate in public toilets by himself to counteract the feeling of shame.
This is what you can do yourself
Parureris always requires behavioral therapy. Together with a therapist, those affected must learn to use public toilets without feeling the typical anxiety. This can be achieved by a gradual approach. For example, patients first visit an empty public toilet before finally going to a more heavily frequented toilet, where they are slowly accustomed to urinating. The aim of this therapy is to eliminate any fear of failure. Relaxation exercises can be used to accompany the therapy. These can be performed either under therapeutic supervision or alone at home. Proven methods include progressive muscle relaxation or pelvic floor training. Both methods facilitate bladder emptying and make those affected calmer and more relaxed overall. If therapy is not possible, for example because the patient suffers from severe paruresis, possibly even as a result of severe trauma, public toilets must be avoided. The most important measure then is prevention. For example, before longer journeys on public transport, it should be ensured that there is no urge to urinate during the journey. If in doubt, sufferers must wear adult diapers or take steps to avoid prolonged travel without access to a private toilet altogether.
