Avoidant paruresis ('bashful bladder' syndrome)

Written by Dr John Pillinger, GP

What is avoidant paruresis?

Avoidant paruresis (also known as 'bashful bladder' syndrome or psychogenic urinary retention) is a social anxiety disorder that involves the inability to pass urine in the presence of others.

Avoidant paruresis can start at any age and affects mainly boys or men, although girls and women can also suffer from it.

The frequency of the condition is difficult to estimate, but surveys suggest that up to 7 per cent of the population may have paruresis, and this figure could be an underestimate.

Why do some people get avoidant paruresis?

The cause of avoidant paruresis is unknown, although a combination of inherent biological factors and factors in the patient's social environment seem likely to play a part.

What are the symptoms?

Being afraid or unable to urinate when others are nearby.

Sufferers worry that someone might knock on the toilet door, or see or hear them urinating, or be waiting patiently outside.

Feelings of anxiety, anger, and body shyness in provoking situations. These emotions lead to contraction of the internal and external urethral sphincters (circular muscles that voluntarily and involuntarily restrict the flow of urine), both of which must be relaxed for urination.

Avoidant paruresis usually occurs when using public toilet facilities, including those on trains, buses, boats and planes.

Producing a specimen for a medical examination can be especially troublesome.

The condition can also occur at home when there are other people in the house, irrespective of whether or not they are in the bathroom.

The difficulty disappears if sufferers are certain that no one is around or likely to arrive.

How is avoidant paruresis diagnosed?

The condition is diagnosed on the basis of the sufferer's account of their symptoms.

In severe cases, sufferers can waste considerable time waiting for everyone else to leave the toilet before they can urinate, and might totally avoid urinating in public toilets. This can seriously limit social activity, prevent people from taking holidays, and in severe cases, even determine their choice of job according to the ease of access to a private toilet.

How is avoidant paruresis treated?

Individuals with avoidant paruresis that is significantly affecting their employment and domestic activities are classified as having a non-generalised social phobia.

Treatment will vary depending on the individual circumstances. No one single treatment has proven effective in all patients and often a multidisciplinary approach to management is necessary.

Treatment aims to enable the sufferer to urinate normally without fear when there are others nearby.

Drug treatment: in some cases, medication is necessary, especially when depression or serious anxiety symptoms are present. Treatment by a GP is possible, although sometimes referral to a psychiatrist may be necessary when anxiety disorders are involved.

Psychological treatment: referral to a psychologist for behavioural therapy has been found effective in reducing paruresis symptoms in several individual case studies. Findings after treatment include a shorter delay in urination, greater urine output, and less anxiety. This initial improvement in symptoms is maintained six months later. Bethanechol chloride, a drug that prompts urination by contracting the bladder muscle, is suggested to improve results of behavioural therapy programmes for paruresis.

Self-catheterisation: occasionally, severely affected patients need to be referred to a urologist to learn how to pass a catheter into the urethra to empty the bladder.

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