To Pee Or Not To Pee

You’re at a ball game with the guys. Everybody’s telling tales, and partying with sodas, and hotdogs and beer. Inevitably, it’s time to make the trek to the men’s room. Once you’re there, you find it boisterous and crowded, with lines to each urinal and no empty stalls. Despite your patience, the crowd thins, but there’s never a time over the next 45 minutes when you have the bathroom to yourself. And, you’ve known for years that you can’t “go” unless you have total privacy. After wandering to the other side of the stadium, you ultimately find an empty handicapped restroom with a locking door! Frustrated and about to bust, you finally can pee. But you make it back to the game having missed almost two full quarters. You offer your prepared excuses and accept the ribbing from the guys, but secretly you’re feeling handicapped by the reality of this embarrassing phobia.

If this scenario sounds vaguely familiar, you have a lot of company. Estimates indicate that 17 million people (or 7% of the population) have degrees of avoidant paruresis–the inability to urinate in the presence of others. This difficulty can occur in public facilities, in a friend’s home, or even in one’s own home if others are present or even within ear-shot. Although 80–90% of people seeking help for this social anxiety disorder are males, it’s estimated that percentages are certainly more balanced in reality. Both sexes, gay and straight individuals, and people of all races are affected by this disorder.

Paruresis can limit social activity greatly. It can prevent people from going on vacations, cause people to waste much time at work as they wait for everyone else to clear the restroom, and can even affect one’s choice or job or career according to the ease of access to private toilets. I have several patients who consistently refuse hunting and fishing expedition invitations with their buddies because of this problem. Bashful Bladder sounds innocent enough, but it can have major detrimental consequences.

Certainly, there are variations of paruresis in terms of degree and triggering factors. For example, some people are “Pee-shy” only under the stress of time pressure or on moving vehicles such as planes, trains, buses, or boats. Some men can urinate comfortably in a closed stall in a bathroom but not in an open line or urinals. The fairly recent addition of partitions between urinals in public restrooms has made it easier for a number of men to urinate publicly because of the extra privacy. And, interestingly, both sexes have a fairly common problem urinating ‘on command’ for urine specimens in a physician’s office or for preemployment drug tests. This phenomenon gives a whole new meaning to the concept of withholding evidence!

Avoidant paruresis is primarily a psychological inhibition of voiding, but the anxiety about urinating actually triggers chemical and neurologic changes that affect the control of the bladder and its sphincters. Increased sympathetic nervous system outflow produces contraction of the internal and external urethral sphincters–both of which must be relaxed for urination to occur.

Although a specific ‘traumatic event’ in childhood (especially early adolescence) which caused embarrassment or unusual stress at the time of urination can be the trigger for this lifetime problem, there is no consensus concerning the exact causes in the general public. Generally, when people have paruresis, they explain that their “plumbing doesn’t work” when they try to urinate in public places or when privacy is not possible. It’s clear that there is no voluntary control over this inability, and Pee-shy folks understand rationally that there is no ‘reason’ they can’t urinate, but phobias cannot be rationalized away. Additionally, into the experiential mix goes the variable of personal space and the comfort threshold that each of us possesses in different settings. There’s some support for a genetic predisposition to paruresis as well, since there is a tendency for the disorder to be found in families; but the evidence is primarily anecdotal at present. So, in summary, the etiology of Bashful Bladder may be a complicated combination of genetic, biochemical, neurologic, and psychologic phenomena. No wonder the treatment plans vary so widely in scope and in success rate as well!

Treatment options include interactive discussion groups, cognitive behavioral therapies–including individual psychotherapy and graded desensitization programs, and sometimes drugs that can either a) help reduce inhibition generally or b) act directly on the bladder and/or its sphincters via the autonomic nervous system. For some folks, learning and practicing the technique of self catheterization may be the only definitive way to control this problem. But the clear message I want to convey here is: there are treatment options for people with paruresis. Don’t feel you’re alone or unusual with this problem; you’ve got 17 million other people for company! The initial step for you might be to contact the International Paruresis Association at 1-800-247-3864, or to email them at:

In addressing any medical problem, the first step is communication. In the instance of paruresis, the issue of embarrassment often present the greatest obstacle to treatment options. There doesn’t seem to be a Quick Fix for anyone, but with directed therapy, you might just go from Pee-shy to the Whiz Kid!

Stephen L. Hines, M.D.
February 2001