Editing Paruresis

{{Short description|Inability to urinate in the real or imaginary presence of others}}
{{Use dmy dates|date=January 2020}}
{{Infobox medical condition (new)
| name            =  Paruresis
| synonyms        = Bashful bladder, bashful kidneys, stage fright, pee-shyness, shy bladder syndrome
| image           = Charles Marville, Urinoir en ardoise à 3 stalles, Chaussée du Maine, ca. 1865.jpg
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| caption         = Outdoor urinal in Paris (1865). Paruresis is a type of phobia in which one is unable to urinate in the presence of others, as in a public toilet.
| pronounce       = {{IPAc-en|ˌ|p|ɑːr|j|ʊ|ˈ|r|iː|s|ɪ|s}} {{respell|PAR|yuu|REE|sis}}<br/>{{IPAc-en|ˌ|p|ɑr|ə|ˈ|r|iː|s|ɪ|s}} {{respell|PAR|ə|REE|sis}}
| specialty       = [[Psychiatry]]
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'''Paruresis''', also known as '''shy bladder syndrome''', is a type of [[phobia]] in which a person is unable to [[urination|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]] or shy bowel.

== Signs and symptoms ==
Some people have brief, isolated episodes of urinary difficulty in situations where other people are in close proximity.  Paruresis, however, goes beyond simple [[shyness]], [[embarrassment]], fear of exposure, or fear of being judged for not being able to urinate. Other people may find that they are unable to urinate while in moving vehicles, or are fixated on the sounds of their urination in quiet restrooms or residential settings. In severe cases, a person with paruresis can urinate only when alone at home or through the process of catheterization.<ref>[http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Paruresis_shy_bladder_syndrome?OpenDocument Paruresis – shy bladder syndrome – Better Health Channel<!-- Bot generated title -->] {{webarchive|url=https://web.archive.org/web/20060902081248/http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Paruresis_shy_bladder_syndrome?OpenDocument |date=2 September 2006 }}</ref>

== Causes ==
Paruresis is considered a symptom of social anxiety and is correlated with other social anxiety symptoms. When the patient is under the effect of anxiolytics or otherwise disinhibited, paruresis tends to disappear.

==Pathophysiology==
It appears that paruresis involves a tightening of the sphincter or bladder neck due to a [[sympathetic nervous system]] response. The [[adrenaline]] rush that produces the [[involuntary nervous system]] response probably has [[peripheral nervous system|peripheral]] and [[central nervous system]] involvement. The [[internal urethral sphincter]] ([[smooth muscle]] tissue) or the [[External sphincter muscle of male urethra|external urethral sphincter]] ([[striated muscle]]), [[levator ani]] (especially the [[pubococcygeus]]) muscle area, or some combination of the above, may be involved. It is possible that there is an inhibition of the [[detrusor]] command through a [[reflex pathway]] as well. The [[pons|pontine]] [[micturition]] center ([[Barrington's nucleus]]) also may be involved, as its inhibition results in relaxation of the detrusor and prevents the relaxation of the internal sphincter.<ref>{{cite journal|title=Paruresis or Shy Bladder Syndrome: An Unknown Urologic Malady?|first1=Steven|last1=Soifer|first2=Greg|last2=Nicaise|first3=Michael|last3=Chancellor|first4=David|last4=Gordon|journal=Urological Nursing|date=2009|volume=29|issue=2|pages=87–94|url=http://www.medscape.com/viewarticle/712369_3|pmid=19507406}}</ref>

==Diagnosis==
The condition is catered for in the rules for mandatory urine testing for drugs in UK prisons, and, also in the UK, a person with paruresis may be eligible for [https://www.gov.uk/health-conditions-disability-universal-credit#:~:text=Universal%20Credit%20is%20a%20monthly,available%20in%20Welsh%20(Cymraeg) Universal Credit] if their health condition limits their ability to work. It is listed in the [[National Health Service|NHS]] approved Healthinote Directory.<ref>{{Cite web |title=Healthinote - Terms Acceptance |url=https://docs.healthinote.com/terms-acceptance?accept_uri=https%3A%2F%2Fpatient.healthinote.com%2FacceptTerms%3Fstate%3D214DqLK1pZN2i8JK5ujYsW%26terms%3Dactivity-5&decline_uri=https%3A%2F%2Fwww.cognitant.com&login_uri=https%3A%2F%2Fpatient.healthinote.com%2Fsearch%3Fq%3Dparuresis%26at%3Dtrue%26fa%3Dtrue&terms=activity-5&ob=abridged |access-date=2025-01-13 |website=Healthinote}}</ref> It is now reported to have been accepted as a valid reason for jury service excusal.<ref>{{cite web|url=http://www.ukpt.org.uk/news_info/projects/activities/news_info_Projects_Recent_Activities_Summary.htm|title=Projects|website=UKPT – United Kingdom Paruresis Trust – Shy Bladder Syndrome Support|access-date=5 August 2018}}</ref> From 1 August 2005, the guidance on the rules relating to the testing of those on probation in the UK cites paruresis as a valid reason for inability to produce a sample which is not to be construed as a refusal.<ref>{{Cite web |title=Paruresis and Drug Testing |url=https://www.ukpt.org.uk/paruresis-information-for-professionals/paruresis-and-drug-testing |access-date=2025-01-13 |website=UKPT - United Kingdom Paruresis Trust - Shy Bladder Syndrome Support |language=en-gb}}</ref>

The condition is recognised by the [[American Urological Association]], who include it in their on-line directory of conditions.<ref>[http://www.urologyhealth.org/search/index.cfm?topic=410&search=paruresis&searchtype=and American Urological Association – Paruresis] {{webarchive|url=https://web.archive.org/web/20090728204000/http://www.urologyhealth.org/search/index.cfm?topic=410&search=paruresis&searchtype=and |date=28 July 2009 }}</ref>

Paruresis was described in section 300.23 of the DSM-IV-TR as "performance fears ... using a public restroom" but it was not mentioned by name.<ref>{{cite book|title=Diagnostic and Statistical Manual of Mental Disorders|url=https://archive.org/details/diagnosticstatis0ed4unse_y1p2|url-access=registration|edition=4th (Text Revised)|pages=[https://archive.org/details/diagnosticstatis0ed4unse_y1p2/page/453 453]|chapter=300.23, Social Phobia (Social Anxiety Disorder|publisher=American Psychiatric Association|date=2000}}</ref> The [[Diagnostic and Statistical Manual of Mental Disorders]] (DSM-5) mentions paruresis by name.<ref>{{cite journal|title=La sindrome della vescica timida|journal= Rivista di Psichiatria|date=Jul–Aug 2013|volume=48|number=4|pages=345–53|doi=10.1708/1319.14632|pmid=24056834|author1=Antonio Prunas}}</ref><ref>{{cite book|title=Diagnostic and Statistical Manual of Mental Disorders|url=https://archive.org/details/diagnosticstatis0005unse|url-access=registration|edition=5th|publisher=American Psychiatric Association|pages=[https://archive.org/details/diagnosticstatis0005unse/page/203 203]|date=2013|chapter=300.23, Social Anxiety Disorder (Social Phobia)|quote=Some individuals fear and avoid urinating in public restrooms when other individuals are present (i.e., paruresis, or 'shy bladder syndrome'.)}}</ref>

''Kaplan & Sadock's Synopsis of Psychiatry'' states, "Persons with social phobias (also called ''social anxiety disorder'') have excessive fears of humiliation or embarrassment in various social settings, such as in speaking in public, urinating in a public rest room (also called shy bladder), and speaking to a date."<ref>{{cite book|title=Kaplan & Sadock's Synopsis of Psychiatry|pages=597|chapter=16.3 Specific Phobia and Social Phobia|author1=Benjamin J. Sadock |author2=Harold I. Kaplan |author3=Virginia A. Sadock }}</ref> The ''Synopsis'' describes shy bladder as "inability to void in a public bathroom" and notes that [[relaxation exercise]]s are an application of behavior therapy for dealing with this disorder.<ref>{{cite book|title=Kaplan & Sadock's Synopsis of Psychiatry|pages=957|chapter=35.8 Behavior Therapy. Table 35.8–2: Some Common Clinical Applications of Behavior Therapy|author1=Benjamin J. Sadock |author2=Harold I. Kaplan |author3=Virginia A. Sadock }}</ref> Some paruretics experience delayed urination and must wait for their need to void to overcome their anxiety, while others are unable to urinate at all.<ref>{{cite book|title=Social Phobia: From Shyness to Stage Fright|author=Marshall, John R.|chapter=The Drama of Social Phobia|pages=[https://archive.org/details/socialphobia00john/page/32 32]|date=1994|publisher=Perseus Books|isbn=978-0465078967|quote=Nurses and others who work in medical offices have long been aware that some individuals are unable to produce urine samples. This phenomenon, sometimes called "bashful bladder," paruresis, is the inability to urinate in public restrooms.|chapter-url=https://archive.org/details/socialphobia00john/page/32}}</ref>

==Treatment==
In terms of treating the mental aspect of paruresis, such treatment can be achieved by [[systematic desensitization|systematic desensitisation]] and [[cognitive behavioral therapy]]. In systematic desensitisation, the subject has a trusted person stand outside the restroom at first, and once the fear is overcome the observer is brought closer in, until step by step the phobia is vanquished.<ref name="Weil 108">{{cite journal|last=Weil|first=Monroe|title=A treatment for paruresis or shy bladder syndrome|journal=The Behavior Therapist|date=May 2001|volume=24|issue=5|page=108|publisher=Association for Advancement of Behavior Therapy|location=New York, NY}} [[PsycINFO]] record [http://psycnet.apa.org/psycinfo/2002-13573-001 2002-13573-001].</ref> There is a detailed description of how the process of systematic desensitisation can be applied for people who have paruresis on the [https://www.ukpt.org.uk/living-with-paruresis/cbt-and-paruresis UK Paruresis Trust website]. In addition to systematic desensitisation, [[cognitive behavioral therapy]] is used to change a patient's mental approach to the condition, from one of a person who cannot urinate, to a person who can urinate or is not overly fearful when they can't publicly urinate.<ref>{{Cite web |title=CBT & Paruresis |url=https://www.ukpt.org.uk/living-with-paruresis/cbt-and-paruresis |access-date=2025-01-13 |website=UKPT - United Kingdom Paruresis Trust - Shy Bladder Syndrome Support |language=en-gb}}</ref> 

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies paruresis as a social anxiety disorder (SAD). In the UK NICE (National Institute for Health and Social Care Excellence) Guidelines set out Recognition, Assessment and Treatment for Social Anxiety Disorders.<ref>{{Cite web |date=2013-05-22 |title=Recommendations {{!}} Social anxiety disorder: recognition, assessment and treatment {{!}} Guidance {{!}} NICE |url=https://www.nice.org.uk/guidance/cg159/chapter/Recommendations#specific-phobias |access-date=2025-01-13 |website=www.nice.org.uk}}</ref>

==History==
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 General Psychology 51:19–29. They surveyed 1,419 college students and found 14.4% had experienced paruresis, either incidentally or continuously.<ref>{{Cite journal |last=Williams |first=Griffith W. |last2=Degenhardt |first2=Elizabeth T. |date=1954-07-01 |title=Paruresis: A Survey of a Disorder of Micturition |url=https://doi.org/10.1080/00221309.1954.9920203 |journal=The Journal of General Psychology |volume=51 |issue=1 |pages=19–29 |doi=10.1080/00221309.1954.9920203 |issn=0022-1309|url-access=subscription }}</ref>

===Other names===
Paruresis is also known by many colloquial terms, including bashful bladder, bashful kidneys, stage fright, pee-shyness, and shy bladder syndrome.<ref>{{Cite web |title=The UKPT - UK Paruresis Trust |url=https://www.ukpt.org.uk |access-date=2025-01-13 |website=UKPT - United Kingdom Paruresis Trust - Shy Bladder Syndrome Support |language=en-gb}}</ref>

==Society and culture==
===Drug testing===
[[Image:Mandatory drug testing, Guantanamo.png|thumb|Observed urine tests can be problematic for those with paruresis.]]
Some drug testing authorities find paruresis a nuisance, and some implement "shy bladder procedures" which pay no more than lip service to the condition{{Citation needed|date=February 2025}}, and where there is no evidence that they have conducted any real research into the matter. In the U.S. [[Bureau of Prisons]], the [[Code of Federal Regulations]] provides that "An inmate is presumed to be unwilling if the inmate fails to provide a urine sample within the allotted time period. An inmate may rebut this presumption during the disciplinary process."<ref>Code of Federal Regulations, Title 28: Judicial Administration, Part 550—Drug Programs, Subpart D—Urine Surveillance, § 550.31 Procedures</ref> Although U.S. courts have ruled that failure to treat properly diagnosed paruresis might violate prisoner's constitutional rights, the courts have also "routinely rejected suspicious or unsubstantiated attempts to invoke it in defense of failure to complete drug testing,"<ref>''Medard v. Doherty'', 2007 NY Slip Op 32130 – NY: Supreme Court, New York 2007</ref> particularly when there were no medical record or physician testimony to back up the claim of paruresis.<ref>In the matter of ''Becker v. Goord'', 13 AD 3d 947 – NY: Supreme Court, Appellate Div., 3rd Dept. 2004</ref>

The International Paruresis Association stresses the importance of medical documentation of one's condition since "[t]he person who is unable to produce a urine sample is presumed guilty in the absence of any evidence."<ref>{{Cite news|url=http://www.paruresis.org/FAQ/faq_page_4.htm|title=FAQ – International Paruresis Association (IPA)|work=International Paruresis Association (IPA)|language=en-US}}</ref> Some prisons have offered the use of a "[[dry cell (prison)|dry cell]]"—i.e., a cell with no toilet facilities, but only a container for the prisoner's waste—as an accommodation to inmates who are hindered by paruresis from providing an observed urine sample.<ref>''Meeks v. Tennessee Department of Correction'', Tenn: Court of Appeals, Nashville 2008</ref>

FBOP Program Statement 6060.08 states, "Ordinarily, an inmate is expected to provide a urine sample within two hours of the request, but the Captain (or Lieutenant) may extend the time if warranted by specific situations (for example, the inmate has a documented medical or psychological problem, is dehydrated, etc.). Staff may consider supervising indirectly an inmate who claims to be willing but unable to provide a urine sample under direct visual supervision. For example, this might be accomplished by allowing the inmate to provide the sample in a secure, dry room after a thorough search has been made of both the inmate and the room."<ref>{{cite web|url=http://www.bop.gov/policy/progstat/6060_008.pdf|title=Urine Surveillance and Narcotic Identification|author=Federal Bureau of Prisons|date=24 November 1999}}</ref> At least six state prison systems—[[Florida Department of Corrections|Florida]],<ref>Florida Department of Corrections Procedure 602.010, mentioned in footnote 12 of {{cite court|litigants=Pate v. Peel|vol=256|reporter=F.Supp.2d|opinion=1326|court=N.D. Florida, Panama City Division|url=http://www.leagle.com/xmlResult.aspx?page=5&xmldoc=20031582256FSupp2d1326_11451.xml&docbase=CSLWAR2-1986-2006&SizeDisp=7|quote=DOC's Procedure 602.010, Bashful Bladder Procedure, which outlines the steps to be taken to obtain a urine specimen from an inmate who claims that he suffers from BBS.}}</ref> [[Massachusetts Department of Correction|Massachusetts]], [[Maryland Department of Corrections|Maryland]], [[Michigan Department of Corrections|Michigan]], [[New York Department of Correctional Services|New York]]<ref>"Procedure for Inmates Claiming to be Unable to Urinate in Presence of Others: The following procedures shall be employed when the watch commander reasonably believes that the inmate is unable to provide a urine specimen due to an alleged inability to urinate in the presence of others (shy bladder). Reasonable belief is based upon the following criteria, including, but not limited to: Medical or mental health records supporting the inmate's claim (to be evaluated by health services or OMH staff), prior disciplinary and/or computerized urinalysis testing data indicating a history of urinalysis testing violations, if applicable, and the inmate's behavior and demeanor at the time of request for the urine sample . . . . Staff shall not witness the inmate urinate into the specimen container." {{cite web|url=http://www.doccs.ny.gov/RulesRegs/20120307_CCS-51-11-00009.html|title=7 NYCRR 1020.4(e)|publisher=New York Department of Correctional Services}}</ref> and [[Tennessee Department of Corrections|Tennessee]]<ref>"There may be extenuating medical (e.g., dehydration, kidney problems, medication, etc.) and psychological (e.g., social phobias) conditions that may preclude the giving of a sample. In such cases, the inmate must provide written evidence from the health care staff indicating such a condition. The Warden shall, in extreme cases, authorize the use of an alternative drug testing method for those inmates who have a documented medical condition that would prohibit the use of urinalysis testing. Approval of the commissioner or his designee is required prior
to the use of any alternate drug testing method or instrument." {{cite web|url=http://www.tn.gov/correction/pdf/506-21.pdf|title=Policy #506.21(VI)(B)(9), Inmate Drug/Alcohol Testing and Sanctions|date=1 June 2011|author=Tennessee Department of Correction}}</ref>—have modified their drug testing regulations to provide accommodations for prisoners with paruresis.<ref>{{cite book|title=Shy Bladder Syndrome|author=Soifer, Steven|isbn=978-1-57224-227-2|pages=98|publisher=New Harbinger|chapter=Evolving Legal Ramifications|date=2001}}</ref>

Per the ''Handbook of Correctional Mental Health'', "No definitive or objective test is available to confirm or refute the presence of paruresis. The absence of prior treatment or the ability to void in some social situations but not in others does not rule it out. Although modalities associated with the treatment of social phobias help some individuals, no universally effective medication or other treatment exists. Coercive interventions, such as forcing fluids while observing a person with paruresis, are ineffective and can cause serious medical complications. Alternatives to observed urine specimen collection for individuals who self-report paruresis include unobserved collections in a dry room, [[Drug test#Hair testing|testing of hair specimens]], [[Drug test#Sweat drug screen|sweat testing]] with a patch, and [[Drug test#Blood|blood testing]] ('Test for Drugs of Abuse' 2002). These alternatives preclude the need for futile attempts to differentiate inmates with true paruresis from those who fabricate complaints."<ref>{{cite book|author=Scott, Charles L.|date=15 October 2009|title=Handbook of Correctional Mental Health|edition=2nd|publisher=American Psychiatric Publishing|isbn=978-1585623891}}</ref>

In the UK the Prison Service has long been aware of and sensitive to this condition, and guidance on how to deal with paruresis sufferers who are selected for Mandatory Drug Testing (MDT) is contained within the working manual used by MDT staff.<ref>{{Cite web |title=Mandatory Drug Testing |url=https://assets.publishing.service.gov.uk/media/6310947a8fa8f504c64e3288/pso-3601-mandatory-drugs-testing.pdf}}</ref>

===Popular culture===
The condition has been occasionally portrayed in popular culture, sometimes for comedic effect or [[parody]]. Examples of this include:
* In the 2005 comedy ''[[Waiting... (film)|Waiting...]]'', a nerdy character with paruresis is one of many bathroom jokes.<ref>{{citation |title= Film in review; Waiting |first= Stephen |last= Holden |date= October 7, 2005 |work= New York Times |url= https://www.nytimes.com/2005/10/07/arts/movies/film-in-review-waiting.html |access-date= 2020-06-09}}</ref>
* In 2015, the International Paruresis Association protested a [[DirecTV]] ad starring [[Rob Lowe]] that portrayed a paruretic as goofy, wearing a fanny pack, and having his hair parted in the middle.<ref>{{cite web|title=Shy bladder group protests DirecTV ad starring Rob Lowe|url=https://www.usatoday.com/story/life/people/2014/11/04/shy-bladder-group-protests-directv-ad/18466771/|publisher=usatoday.com|access-date=19 January 2016}}</ref>
* In the American sitcom ''[[The Big Bang Theory (TV show)|The Big Bang Theory]]'', the character Penny is revealed to suffer from bladder shyness.

==See also==
* [[Japanese toilet#The Sound Princess|The Sound Princess]]

==References==
{{Reflist}}

==External links==
* [http://www.paruresis.org International Paruresis Association]
* [http://www.ukpt.org.uk United Kingdom Paruresis Trust (UKPT)]

{{Mental and behavioral disorders|selected = neurotic}}

[[Category:Urological conditions]]
[[Category:Shyness]]
[[Category:Anxiety disorders]]
[[Category:Body-related phobias]]
[[Category:Situational phobias]]