Paruresis – The Bashful Bladder Syndrome

In contrast to physiological conditions like prostatitis (inflammation of the prostate) that block the flow of urine, BBS is a psychological disorder that involves the urinary system. More precisely, BBS is a type of social phobia, meaning the paruretic is usually shy and fears being scrutinized or criticized by others when performing in public, in this case, urinating in a public restroom. The psychological conflict that generates this particular form of social phobia is expressed through the physical symptom of being unable to urinate whenever the person desires.

The experience of BBS varies somewhat from person to person; however, certain general patterns are evident. First, BBS occurs mostly in public restrooms, but it can also occur in the homes of friends and relatives, or even at home if visitors are nearby or a family member is waiting for the paruretic. Typically, though, she or he finds the home bathroom to be the only truly safe toilet, the only place where the paruretic is consistently able to urinate.

Second, BBS ranges in intensity from mild, in which the person can urinate in public facilities under certain circumstances, to severe, in which the person can only urinate when alone at home. Thus the degree of BBS hesitancy ranges from a momentary delay in initiating the process to chronic and acute retention. Most people occasionally experience at least some hesitancy in public restrooms, but this differs from BBS in the matter of degree and context. A person who every now and then must wait an extra second or two before being able to urinate is not a paruretic. Rather, BBS is often a life-long condition characterized by excessive hesitancy or a total inability to urinate. The problem also causes distress over everyday activities like travel, social engagements, long business meetings, and interferes in a significant way with the paruretics ability to carry on with these normal activities.

Third, most paruretics describe a personal comfort threshold required for urinating, whether in public facilities or at home. When this comfort threshold is eclipsed by too many negatives in a particular situation such as noise, odors, lack of visual privacy, and other people in the restroom talking, BBS kicks in and prevents the person from urinating at that time.

Typical Characteristics of BBS

What are some of the triggers for BBS? Paruretics most commonly refer to three triggers that influence them when in public restrooms. For the typical paruretic, these triggers must be removed, or the person must try another toilet for urination to occur on a particular occasion.

First, familiarity with other people present in the restroom can trigger BBS, with strangers usually (but certainly not always!) leading to greater inhibition than friends or relatives. Because of the personal nature of elimination, the degree of familiarity and perceived acceptance often determine whether or not the paruretic will successfully urinate.

Second, proximity plays a role in the problem. Proximity for the paruretic is both physical, involving the relative closeness of others in or near the restroom, and psychological, involving the need for privacy. The most frequent complaint about physical stimuli in public facilities is the absence of suitable partitions and doors on stalls. Many paruretics remark that they cannot urinate (or defecate) in a stall toilet if the door is missing. They feel embarrassed about their personal space being invaded visually.

Discomfort with lack of partitioning is central to the issue of perceived lack of privacy in public restrooms. Of course, the perception and need for privacy differ considerably across people. One individual is comfortable only at home with the bathroom door locked, while another is comfortable using a urinal in a crowded restroom. Paruretics tend toward the former.

Third, temporary psychological states, especially anxiety, anger, and fear, can interfere with urination. Social phobics who are overly sensitive about the sounds and smells they make while urinating are usually fearful of being criticized for such, which in turn arouses their nervous system. Also, excessive emotional states may explain why attempts to urinate under favorable conditions are often unsuccessful if the individual is overly excited or feels pressured to hurry.

Typical Behavioral Patterns

For some individuals BBS appears to start out of nowhere, but for most an unpleasant experience or group of experiences appear to precipitate the onset of the problem. In the case of the latter, after some negative event such as being unable to urinate in front of a nurse during a medical test, the individual begins to catastrophize; that is, he or she worries about being able to urinate next time he or she is in some type of public restroom. In this way performance anxiety, the key feature of social phobias, develops and becomes associated with urinating in the presence of others. The individual enters public restrooms with aroused sympathetic nervous system activity, which creates a level of anxiety that is incompatible with urinating. As each forcible attempt to control the process fails, increased performance anxiety due to mounting levels of sympathetic activity decreases the individuals chances of voiding at that time. In many cases this performance anxiety eventually generalizes to all or most public restrooms, so that the only safe toilet the person can reliably use is at home.
Generally, paruretics try to adjust to the problem by urinating as much as possible when at home and before leaving their home toilet, restricting the intake of fluids, and refusing extended social invitations. Most paruretics also perform a series of rituals, such as locating vacant restrooms whenever away from home, thinking of water when trying to urinate, and running the tap to optimize the chances of urinating under adverse conditions. Most commonly, though, paruretics cope by avoiding public restrooms at all costs.


Seek a medical evaluation before attempting to treat bashful bladder problem. Rule out a medical condition before diagnosing paruresis. However, a general rule of thumb is that if you can go at home when alone without a problem, but have difficulties in most or all social situations, then you probably suffers from paruresis.
The most commonly used treatment for bashful bladder involves the individual gradually attempting to urinate in more and more difficult locations. This treatment is usually called behavioral exposure therapy. Each session of exposure therapy involves several attempts at briefly urinating.


Concrete Steps

For those suffering from paruresis or who know of someone who suffers from this social phobia, there are things one can do:
Visit the website at and get the latest information about this anxiety disorder. There is a moderated discussion group accessible through the website, as well as a place to ask questions.
If you  haven’t done so, start talking to your loved ones, friends, relatives, and co-workers about paruresis. A very typical response is: Oh, I know someone who suffers from that, or even, You know, I have that problem too!
Join the International Paruresis Association (IPA), a tax-exempt, non-profit organization, to keep informed about the latest developments on the topic. The IPA, Inc. acts to educate the public, gather and disseminate useful information, and seek effective treatments for paruresis. Also, IPA can refer you to a cognitive-behavioral therapist to help you with your paruresis.
More than anything else, ongoing practice on a weekly, or even daily basis, will allow you to overcome or recover from your paruresis in a timely manner. Persistent, consistent practice is essential for improvement.

Paruresis and Drug Testing

These days, many people face drug testing in either their workplace, or in some cases, prisons.

There is no clear answer to the question: Can I get around giving a urine sample under scrutiny at my workplace or in prison? For those working in publicly funded jobs, the Americans with Disabilities Act (ADA) may protect you from random urine drug testing. This may also be true in the private sector.
The way to approach the problem is by being straightforward with your employer. Let the employer know that you suffer from an anxiety disorder named paruresis, which is a bona fide social anxiety disorder listed in the Diagnostic Statistical Manual of Mental Disorders (DSM) IV with code 300.23, and that under the ADA, you should be given reasonable accommodations in terms of drug testing. This means that the employer should allow you to give a hair or blood sample instead of a urine sample. If you belong to a union, you should also advise them of your status so that they will support you in case of disciplinary action. You should also have a doctor, urologist, psychologist or psychiatrist document your condition, and preventive action is advised.


Published by

Dr. Gnap

Dr. Gnap is a family practice physician and behavioral medicine specialist in suburban Chicago.  Dr. Gnap developed the Inner Control™ Program in 1970 and has worked with thousands of people to improve and correct medical, emotional, behavioral and learning problems including performance.  He started the Inner Control program because so many patients asked, “what more can be done along with traditional treatment methods?”

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