What Is Shy Bladder Syndrome (Paruresis)?

Introduction

Have you ever found it difficult to urinate (pee) around others? If the answer is yes, then you might be suffering from shy bladder syndrome. It’s a condition where someone finds it difficult to start or continue to urinate when around other people. This often leads to a fear of urinating in public toilets, which can affect everyday activities in its most severe form. If you struggle with shy bladder syndrome, know that you are not alone. The condition affects around one in fourteen of us.¹ But thankfully, it is a condition that can be treated, meaning that those it affects will be able to lead a normal life. Learning to recognise the signs of shy bladder syndrome and understanding how to deal with it will help you to overcome its challenges and improve your quality of life. This article explores the causes and triggers of shy bladder syndrome, discusses the most common symptoms, how it is diagnosed, and the options available to help you manage the condition.

Understanding shy bladder syndrome

Shy bladder syndrome (SBS) can affect anyone of any age, but it is usually most common in men.² It is often described as a feeling that the bladder is “locking up” or “tight” by those it affects.³ Shy bladder syndrome is known within healthcare as paruresis or urinary retention, but other names include ‘shy bladder’, ‘bashful bladder’, and ‘pee shy’.⁴ It is estimated that around four million in the United Kingdom cannot urinate in public toilets due to the condition.⁵ Shy bladder syndrome affects people differently.⁵ Some may only experience fear in response to specific situations, whilst others may experience severe fear that affects their quality of life.⁵

Causes and triggers

Psychological factors

Shy bladder syndrome is considered a form of social anxiety and is thought to be related to psychological factors, including:

• Anxiety
• Fear
• Trauma⁵

Environmental factors

Shy bladder syndrome can also be caused by factors of the surroundings, including:

• Having a negative experience when using the toilet
• Learning the behaviour of someone else, such as a parent
• Being in a place where others may hear or see you urinate e.g., a public toilet
• Feeling pressured by knowing that, for example, a friend is waiting or there is limited time to use the toilet.⁵

Common symptoms

Physical symptoms

Someone with shy bladder syndrome may experience:

• Being unable to start or continue urinating when not being on their own
• A feeling that your bladder is ‘locking up’ or ‘tight’ when urinating around others
• Pain of the bladder when it’s full and a person is not able to empty it
• Symptoms of anxiety (e.g. increased heart rate, shaking, and sweating).⁵

Behavioural symptoms

Individuals with shy bladder syndrome usually display avoidant behaviours, such as:

• Urinating at home to avoid having to use public toilets, in more severe cases, avoiding going out or socialising altogether
• Finding public toilets that are empty to be able to urinate
• Avoiding long journeys by car, on the train or on long-haul flights
• Drinking less water and other fluids.^4,5,6

Psychological symptoms

Shy bladder syndrome causes anxiety-related symptoms, such as:

• Fear of using public toilets and urinating in public
• Fear of urinating when visiting others or having visitors at home 
• Feeling anxious when you need to use the toilet in the presence of other people
• Worrying that others will hear or see you urinating.⁷

The vicious circle of anxiety

Shy bladder syndrome, like other forms of anxiety, can be characterised by what is known as a vicious circle.⁵ In this circle, the fear of urinating around others creates a cycle that keeps the anxiety going, which can lead to further anxiety and fear around urinating.⁵ 

The circle continues to present itself through a repeating pattern of the following events:

1. The trigger: This can be specific to each individual with shy bladder syndrome, but will usually need to urinate in a public toilet or around others.⁵
2. Fear and anxiety: When faced with a trigger, a person with shy bladder syndrome experiences fear and anxiety.⁵ This can cause physical responses, including not being able to urinate properly. This can lead to even greater anxiety.
3. Avoidance behaviour: To cope with this anxiety and avoid potential embarrassment, the person may engage in avoidance behaviours.⁵ This can include leaving the toilet, waiting until it is empty, or avoiding public toilets altogether.⁵
4. Anxiety relief: The avoidance behaviours relieve anxiety temporarily but later return when faced with another trigger.⁵ 

Being able to recognise when you are in vicious circle of anxiety can help you to recognise what your triggers are and how you react to them. This will also help you to identify the most effective ways to tackle these thinking patterns and relieve your symptoms. 

Potential complications and long-term consequences

If left untreated, shy bladder syndrome can lead to:

• Urinary tract infections (UTIs), affect the bladder, urethra and kidneys due to not flushing out bacteria in urine as often as needed
• Kidney damage as a result of an UTI
• Abdominal pain, as the full bladder can’t be emptied.⁸

Treatment and management

There are many options available for dealing with shy bladder syndrome, which your healthcare provider can help guide you through. Not all options will work for everyone, so it is important to try and find the strategies that work best for you. 

Lifestyle and self-help strategies

The following strategies are ones that you can easily do yourself and incorporate into your daily routine.⁵ They are not only good for managing shy bladder syndrome but are proven to be good for your overall health and wellbeing.⁵

Relaxation techniques

Relaxation training is an effective tool for individuals dealing with shy bladder syndrome.⁵ This technique aims to relieve physical tension in the body, a common symptom experienced in triggering situations for those with the condition.⁵ 

Exercise

Exercise is a great way to help people deal with shy bladder syndrome. It does not just help your physical health, but it is also good for your mental health.  Physical activity causes your body to release chemicals called endorphins, which make you feel happier.⁵ This can help:

• Reduce your overall anxiety levels and any anxiety from shy bladder syndrome.
• Lower your stress levels.
• Improve your self-esteem, helping you to feel more confident in triggering situations such as urinating around other people.⁵

Gradual exposure

Although avoidance behaviours only provide a quick fix that makes us feel less anxious in the short term, gradual exposure helps to reduce anxiety in the long term.⁵ Rather than tackling your fear all at once, gradual exposure allows you to tackle it in stages, from small to large. Here are some tips for managing shy bladder syndrome with gradual exposure:

1. Make a list of all the situations that make you anxious, starting from the least to the most severe
2. Expose yourself to the situation that is lowest on your list
3. Practise as regularly as possible and work your way up the list as you continue
4. Get support from someone you feel comfortable with during the process.⁵

You can access additional resources for people living with shy bladder syndrome on the UKPT website, offering advice such as ‘Ten steps to take charge of paruresis’ and videos explaining how cognitive-behavioural therapy strategies could help with your condition.  

Professional help

Alternatively, if lifestyle and self-help strategies are not suitable for you or you need additional support, seeking help from professionals is also a great option. Some people may find that a blend of both techniques is the most effective, but others may find one more useful than the other. 

Cognitive-behavioural therapy

Cognitive-behavioural therapy (CBT) is a strategy that is based on the vicious circle of anxiety, so it can help individuals with shy bladder syndrome.^5,9 It helps to change negative thinking patterns and behaviours that maintain anxiety around urinating in public spaces or in the presence of others.^5,9 Your primary care provider should be able to direct you to services that provide CBT, such as NHS Taking Therapies. Cognitive-behavioural therapy helps you to address the problem in stages:

1. Spotting your negative thoughts and taking a close look at them
2. Helping you to look at your thoughts differently 
3. Review your thoughts
4. Testing the thought to see whether it was helpful or not.⁵

Medications

Medication is also an option for treating shy bladder syndrome. You can discuss your symptoms with your primary care provider, who can then decide if medication is a suitable option. If you are prescribed medication, it will likely be a medication used to treat anxiety, such as anxiolytics antidepressants.⁵

Conclusion

Shy bladder syndrome is a common problem faced by many individuals, which makes it difficult for them to urinate around other people. It is a very real condition that should be taken seriously, as it can severely impact the mental well-being of individuals. Similarly to other anxiety issues, shy bladder syndrome is reinforced by a vicious circle and can lead to a range of physical, behavioural and psychological symptoms. Being able to recognise these symptoms is a crucial step in addressing the burden that shy bladder syndrome places on its sufferers. 

There are a range of treatment options available to help you manage shy bladder syndrome, including lifestyle and self-help strategies, professional help, and medication. If you are suffering from shy bladder syndrome, or have any of the mentioned symptoms, consult your healthcare provider who will be able to support and guide you. Having shy bladder syndrome is nothing to be embarrassed about, and it is something that can get better with the right support.