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Are You Pee-Shy?

A cup runneth over.

So, how does one come to find it difficult-or impossible-to urinate in the presence of others, whether the setting be a public facility or what had heretofore been the sanctuary of Home Sweet Home? The victims of "shy bladder syndrome" have a fear of leaving the house and being unable to find a "safe" toilet. They are thought by some to have an anxiety disorder, a type of social phobia, and yet it is rarely discussed by the sufferer. To paraphrase Lord Alfred Douglas, it is the fear that "dare not speak its name". Those who suffer from paruresis are quite literally remaining in the water closet: Many simply cannot urinate despite how uncomfortable they may be.

Shyness is nice, and
Shyness can stop you
From doing all the things in life
You'd like to.........
-----The Smiths

Aside from the suffering and embarrassment of having this "bashful bladder", a number of avoidance behaviors accompany paruresis that can be damaging to physical well-being: For example, sufferers might refrain from drinking fluids to avoid the use of a bathroom when away from home, risking dehydration, urinary tract infection and potential kidney damage.

I recall one patient of mine who complained of recurrent pain and pressure in the bladder while at work. He and I embarked on a urological work-up, measuring urinary retention and urine velocity, taking lab tests and undergoing advanced radiological evaluation, all of which were unrevealing. Finally, he explained to me his fear of urinating at the workplace, and any other public setting. His problem was a full bladder which he was only able to empty in the quietude of his home.

Is paruresis the result of our puritanical society? For males at least, is it a manifestation of castration or penis size anxiety, particularly when standing before that most intimidating of inventions, the wall-mounted urinal, shoulder to shoulder with a stranger? Is the relative dearth of public toilets in this country contributing to paruresis? I wonder whether the citizens of Nepal, where there are few private or public toilet facilities, experience pee-shyness.

A few large United States cities actually have the locations of their public restrooms available on websites, which might be superficially comforting to some. And of course there is (and the iPhone app SitOrSquat), which can locate a toilet or restroom anywhere in the world. Still, it can be daunting to find a restroom in this country, particularly when many are restricted to "customers only". In contrast, in Italy for example, restaurants and bars are required by law to permit anyone-customer or no-to use the restroom.

Henry Miller wrote almost lovingly of the "pissoirs" in Paris, where the public was able to see all that went on at the lower part of those open air facilities; set among the throngs of the boulevards, it was more akin to a typical stall which we know to be hidden behind closed doors in this country. The urine of urination was nothing to be ashamed of. However, of New York City, Miller wrote, "I know that I am in distress when I walk the streets of New York. Wondering constantly where the next stop will be and if I can hold out that long". Sigmund Freud, upon his triumphant visit to New York, complained, "They escort you along miles of corridors and ultimately you are taken to the very basement where a marble palace awaits you, only just in time".

This country appears to have made relieving oneself a chore, and even something of which one is to be ashamed. It is with furtiveness we seek the restroom, and once there it is difficult to turn off that fight-or-flight attitude, for those with the shy bladder have such difficulty in letting their defenses down.

Aside from moving to Europe, what should be the therapeutic approach to paruresis? Cognitive-behavioral therapy appears to be the best option. There have been some reports of using gabapentin, atenolol and psychotropic drugs; but pharmacologic intervention has not been very effective, and in fact can contribute to urinary retention and difficulty emptying the bladder.

Perhaps 7% of the population of the United States is afflicted with paruresis. At least the paruresis patient can take comfort that he or she does not sit, squat or stand alone.

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