Here’s a scenario you may find familiar: You’re out in public and you realize that your bladder is excruciatingly full. You can't hold it; you need to pee. So you find a public restroom. But when you sidle up to the urinal, or settle into a stall, you find that—in such close proximity to others—you just can’t go. Maybe you have to wait until everyone else leaves the restroom before you can finally empty your bladder. Maybe you have to just give up and leave, unsatisfied and anxious about your failure to fulfill a basic bodily function no one else seemed to have trouble with.
Many who experience these or similar difficulties feel isolated, like they are uniquely deficit in the urinary department. But they are not. Although they rarely speak openly about it openly, millions worldwide have trouble peeing in public every day. The experience is common enough that it’s referenced, albeit often not sympathetically, in shows like Family Guy.
What Is Shy Bladder Syndrome?
Often known informally as bashful bladder, pee shyness, or shy bladder syndrome, this condition actually has a proper medical name: paruresis. Latin for “abnormal urination," paruresis is chronically under-discussed, even in medical and mental health circles, furthering the sense of isolation and oddity among those who have it. But it is an officially recognized social anxiety disorder. And specialists understand paruresis well enough that they can treat, and even functionally cure, the disorder in the vast majority of those who experience it.
Typically we go through life holding urine in our bladders by subconsciously constricting our urethral sphincters. A few times a day, when we approach a toilet, we instinctively and subconsciously ask our sphincters to loosen, releasing urine. When one has paruresis, though, low-grade or acute anxiety causes our sphincters to lock up rather than loosen. For some, this may pass as they relax mentally, leading just to a delay in their ability to pee. But if one starts to feel more anxious about this initial delay, and gets more and more into their own head with negative self-talk or doubt, they will continue to lock up their sphincters and wind up entirely unable to empty their bladder.
Paruresis is not the only issue that can cause people trouble peeing. Prostatitis, for example, can cause inflammation that blocks the flow of urine leading to difficulty peeing. Excessive drinking can also overstretch a bladder, making it hard for the organ to contract and push out urine. As such, paruresis is usually diagnosed when someone reports being able to pee just fine when alone at home, but not in public, nailing down the difficulty to social anxiety rather than a physical root.
According to the International Paruresis Association (IPA), a leading clearinghouse of information on the condition, up to seven percent of Americans—more than 20 million people—experience paruresis. The IPA's president, Steven Soifer, started recovery for his own paruresis in 1996. Soifer tells me he once estimated the global prevalence, based on existing surveys, at about 120 million people. Not all of these people deal with the condition to the same extent: Some, for instance, might only experience paruresis every now and then, perhaps during periods of fleeting but high anxiety—say, after downing a ton of caffeine. Some might be fine peeing so long as they have a urinal of buffer space or their own stall. Others may be so anxious about public restrooms that they can only go when they are fully alone, in their home toilet.
“This is a continuum disorder,” Soifer says, noting that everyone basically develops their own privacy zone and factors within which they are comfortable peeing. For some, those are so minimal that they can pee while crossing streams with someone else. For others, they’re so intense that even having someone else in their home, or sharing thin walls with a neighbor, is enough to make their own bathroom seem unsafe, causing them to have problems urinating even when alone at home.
How Common Is Shy Bladder Syndrome?
By some estimates, between one and two million Americans have such bad paruresis that it inhibits their ability to go out and socialize or to hold down a normal job. (In one case, a man reported that he became a janitor just so he could put up out of order signs to achieve some privacy.) Or it leads people to hold it so long while they’re out that they overstretch and damage their bladders, cause UTIs, or risk kidney damage or stones. “In some cases, patients have needed medical intervention, by being catheterized, in order to void” their bladders at all, says John Montopoli, a behavioral therapist who works with many patients with paruresis,.
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According to the IPA, hundreds or thousands of Americans have also likely lost their jobs because of their paruresis, thanks to the prevalence of mandatory urinary drug testing, often performed in uncomfortable settings for paruretics. People can challenge terminations based on their inability to complete a drug test in a hostile bathroom environment based on the Americans with Disabilities Act. But this is often a difficult process, and requires a proper medical diagnosis. Prisoners with paruresis face similar challenges, too; failing to fill a cup in an uncomfortable bathroom setting can get them punished under the assumption that they have been doing drugs while incarcerated.
What Causes Shy Bladder Syndrome?
No one is entirely sure how paruresis develops, or what makes some cases worse than others. However, both Montopoli and Soifer note that the condition doesn’t seem to have anything to do, as one might assume, with the vulnerability of urination and an attendant nervous feeling of proneness. Nor does it seem, for men, to connect to insecurities about others judging their genitals.
In many instances, though, Montopoli and Soifer say, people with paruresis believe they can trace their anxiety back to a moment in (usually but not always) childhood when they felt particularly judged for or embarrassed about how they peed or how long it took them to start peeing. Soifer recalls being a child at a urinal, feeling uncomfortable as other boys tried to watch him pee. He says he fled to a stall, but then the other boys tried to break down the door, still intent on seeing how he might be different. These memories are hardly universal, but they are an incredibly common thread, pointing to a moment of negative learning that develops into an anxiety that just gets reinforced over time.
Montopoli says the majority of men he works with who suffer from paruresis speak of “a fear of other men thinking of them as less of a man for not being able to ‘pee on demand.’” In rare cases, he adds, they may also be afraid that lingering at a urinal or stall will make them seem like they’re cruising for sex. Soifer adds that some are more worried about people hearing their urine hitting the toilet bowl or water than they are about being noticed and marked as deficient males.
Not everyone who gets razzed in the bathroom as a kid will develop paruresis. This leads Soifer to suspect that some people have a mental or physical propensity to develop the disorder while others don’t. Physical or psychological differences may account for the varied intensity with which the disorder can hit people as well. What these differences might be, though, remains murky.
If paruresis is rooted in negative learning and association, that may explain why the disorder seems so much more common amongst men than women in America. The IPA doesn’t have any firm gender breakdowns, but Soifer notes that whenever he goes to paruresis events in the States, they are overwhelmingly male. Women’s restrooms have more privacy, he notes, offering fewer chances for the kind of bullying and embarrassment many men experience growing up.
However, American restrooms still offer women many potential stressors. Soifer notes that some female paruretics say they hate seeing feet under a stall, or feel pressured by bathroom lines. The IPA notes that it's possible women suffer paruresis at similar rates to men and we just don’t notice due to limited space for them to come forward in cultural conversations, or other visibility or reporting issues. At the very least, no one I spoke to for this piece was aware of anything that would inherently lead to a gendered disparity in paruresis, under the right cultural circumstances. Still, differing norms about bullying, privacy, bathroom design, and so on certainly likely explain why paruresis seems to be far more or less common in some countries than others.
How Do People Treat Shy Bladder Syndrome?
For all the pain and trouble it can cause those who experience it, paruresis is actually shockingly easy for many to overcome once they acknowledge the problem. People with paruresis have developed a slew of techniques for relaxing their bodies and minds to allow them to pee, according to several testimonials. These relaxation techniques, like breath holding, may not work for everyone, Soifer notes. But usually someone can eventually find some set of coping mechanisms to help them through the day.
Paruresis also responds well to a form of short-term cognitive behavioral therapy called graduated exposure therapy. This process involves, over the course of a few months, peeing first while in a comfort zone, then slowly pushing that comfort zone until one can find relief even in their worst nightmare public restroom situation. Sometimes the process is easier with a “pee buddy,” who will work with someone to slowly close his or her privacy zone using comfortable settings and a trusting relationship. This process works regardless of whether one understands the roots of their paruresis.
Soifer maintains that 80 to 90 percent of paruretics can find relief through exposure therapy. Some might even be able to perform this therapy on themselves, with the right motivation. The only folks for whom it might not work, he says, are those with parallel issues, like extreme depression or alcoholism, that may be getting in the way. For these people, though, he argues, the answer is not to go out and buy some instant cure, a number of which are hawked online and are of dubious value. Instead, he says, they ought to just deal with their other issues first, and use coping mechanisms—maybe even catheterization if needed—to manage their paruresis in the meantime.
Just because paruresis can be cured, that doesn’t mean it isn’t an issue. Knowledge about the condition and the ways it can be dealt with remains incredibly low, even among counselors, urologists, and other frontline providers likely to first encounter people who have it. This lack of visibility and awareness means that many people may not find the help they need and instead sink into a sense of isolation and stigmatization that allows their condition to spiral. As such, a large part of the IPA’s work is still running support groups and publicizing the disorder—as well as working for drug testing reform and advocating for more privacy in bathroom designs worldwide.
Paruresis will probably never vanish from the world. But the more we talk about this little-acknowledged disorder, the more likely it is that those who develop it will be able to recognize their symptoms and get help, eventually finding complete relief, rather than suffering in stigmatized isolation.
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