Paruresis

Editor(s)-in-Chief: C. Michael Gibson, M.S.,M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Steven C. Campbell, M.D., Ph.D. [mailto:campbes3@ccf.org] Phone: 216-444-5595, Professor of Surgery, Residency Program Director, Section of Urologic Oncology, Glickman Urological and Kidney Institute, Cleveland Clinic.

Overview
Paruresis (IPA ), also known as pee shyness, shy kidney, bashful bladder, stage fright, urinophobia or shy bladder syndrome is a type of social anxiety disorder, that can affect both men and women, in which the sufferer is unable to urinate in the (real or imaginary) presence of others, such as in a public restroom. The analogous condition that affects bowel movement is called parcopresis.

Impact
Many people have brief, isolated episodes of urinary difficulty in situations where other people are in close proximity, and this is sometimes described as "stage fright". However, that is to be distinguished from paruresis.

Paruresis goes beyond simple shyness, embarrassment, or desire for privacy in that it is much more severe and may cause unnecessary inconvenience, because the inability to urinate, although psychological in origin, is physical in its effect, and not under the control of the sufferer. Paruresis can be mild, moderate or severe. In mild cases, paruresis is an occasional event, like a form of subconscious performance anxiety. For example, a man at a public urinal may be surprised to find it difficult to urinate when flanked by other men, possibly because he may be worried about them seeing his penis, while others may find that they are unable to urinate while in moving vehicles. In severe cases, a person with paruresis can urinate only when alone at home.

Although most sufferers report that they developed the condition in their teenage years, it can strike at any age. Also, because of the differing levels of severity from one person to another, some people's first experience of the problem is when, for the first time, they "lock up" attempting to produce a sample for a drug test.

Severe cases of this disorder can have highly restricting effects on a person's life. Severe sufferers may not be willing to travel far from their home. Others cannot urinate even in their own home if someone else can be heard to be there.

Origin of the term
The term Paruresis was coined by Williams and Degenhart (1954) in their paper "Paruresis: a survey of a disorder of micturition" in the Journal of Psychology 51:19-29. They surveyed 1,419 college students and found 14.4% had experienced paruresis, either incidentally or continuously.

General recognition
There is growing recognition of the condition by the United Kingdom's National Health Service and UK government. The condition is catered for in the rules for mandatory urine testing for drugs in UK prisons, and UK incapacity benefit tribunals also recognise it. It is listed in the NHS on-line encyclopaedia of conditions and disorders. It is now reported to have been accepted as a valid reason for jury service excusal. From 1st August 2005, the guidance on the rules relating to the testing of those on probation in the UK, explicitly cites paruresis as a valid reason for inability to produce a sample which is not to be construed as a refusal.

The condition is recognised by the American Urological Association, who include it in their on-line directory of conditions.

It has, from time to time been the topic of advice columns such as Ann Landers, to which sufferers have written in and been counselled on their problem.

In DSM-IV TR, it is classified as a social phobia.

Context and urine samples
There can be serious difficulties with workplace drug testing where observed urine samples are insisted upon, if the testing regime does not recognise and cater for the condition. In the UK, employees have a general right not to be unfairly dismissed, and so have an arguable defence if this arises, but this is not the case everywhere.

There is growing evidence to suggest that some drug testing authorities find paruresis a nuisance, and some implement "shy bladder procedures" which pay no more than lip service to the condition, and where there is no evidence that they have conducted any real research into the matter.

The codes and procedures for drug testing in sport are set by the World Anti-Doping Agency ("WADA"). Enquiries to WADA reveal that their doping codes do not cater for the condition at all, and they say they have never had any reports of problems with it. It is thought to be remarkable that such a widespread common condition is not experienced by any athletes, and it is believed by some that this is because sufferers avoid activities where they know they will be required to submit to such testing without the right to choose an alternative testing method. If that is correct, then there might well be a vicious circle which would be of the nature of potential world class athletes who are sufferers being deterred by the testing regime, whilst the testing regime does not cater for the condition because it has not encountered sufferers.

Treatments and strategies
There are a number of "work-arounds" that address the symptom and not the problem:
 * drinking less fluid and emptying out whenever 'safe' (although this can be dangerous and lead to dehydration)
 * avoidance of large or busy public restrooms
 * finding less-busy or single-occupancy restrooms
 * returning to a specific bathroom or stall which is familiar and feels safer
 * using bathrooms on other floors or in other buildings to avoid familiar persons
 * timing bathroom visits to avoid the presence of others (solitude)
 * timing bathroom visits to correspond to heavy usage by others (masking effect from noise, greater anonimity)
 * tickling the buttocks
 * running the tap or flushing to mask urination sounds
 * thinking about water flowing
 * using a catheter
 * using a stall instead of a urinal
 * closing ones eyes and imagining no one is there
 * focusing on a single point or thought (with or without eyes open)
 * holding one's breath, forcing urination to begin before the next breath is taken
 * combination of two or more of the preceding techniques

Actual treatments for the condition include:
 * cognitive behavior therapy,
 * training with biofeedback,
 * anti-anxiety medications, and
 * reducing the level of privacy at which the condition triggers by indulging in graduated exposure therapy. This last can be achieved by sufferers working together at organised events known as workshops.