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May 18, 2016

Infrequently Asked Questions: What causes shy bladder syndrome?

The world is full of questions we all want answers to but are either too embarrassed, time-crunched or intimidated to actually ask. In the spirit of that shared experience, we've embarked on a journey to answer all of the questions that burn in the minds of Philadelphians — everything from universal curiosities (Why do disposable coffee cups still leak?) to Philly-specific musings (How does one clean the Liberty Bell?). 

Just when you've gotta go — like, really go — someone unzips at the urinal next to you. And just like that, you're frozen. What's with the liquid stasis?

We reached out to Cooper University Hospital Assistant Professor of Urology Jeffrey Tomaszewski for an answer. 

Imagine you're in a public restroom and someone drops by right next to you to take care of their business. Suddenly you can’t pee. Why’s that happening?

Yeah, so it’s actually probably pretty common. People call it ‘shy bladder syndrome,’ or the medical term is paruresis, but people often call it lazy or shy bladder, and it really is almost in the category of phobias or a social phobia. It almost fits under something not necessarily wrong with the bladder or prostate itself, but people have, for one reason or another, developed a subconscious fear of urinating in the presence of others. It can be something that relates to childhood — that they were embarrassed by something during potty training, or teased by a classmate or sibling, or even harassed in a public bathroom. And even more rarely, something like sexual abuse. In general, it’s hard to estimate how many people it affects, but it probably affects a lot of men who just don’t talk about it.

How does the psychological piece of this physically stop us from peeing?

So basically, what happens is your bladder is a reservoir for urine. And when it fills it sends signals to your brain that it’s full, and your brain responds by making the bladder contract, relaxing the sphincter or valve to open up the outlet and let you urinate. What happens in this setting is — no one understands exactly how it works, but if you think of it in terms of the fight or flight response, when you’re in a state of panic or flight, the kind of body functions not necessary — like urination, defecation — sort of gets repressed by your nervous system. If you have a fear response to people around you, it can actually send signals to your bladder not to work. And essentially, it blocks that signal from the brain to the bladder that you should be urinating. So nobody really understands why it happens, but the thought is that’s the general mechanism. 

Does this impact women, too?

We really only talk about it with men, and part of that is the way in which we use urinals. Women usually have private stalls and are seated, and men have standing urinals. 

But that’s not always the case. Some people have forms of this disorder [so bad] they can’t go in a public restroom at all. Like on an airplane even though the door is closed. They need complete privacy. And it absolutely probably happens in women as well, it's just a lot less recognized and talked about, and we don’t really see any women come into my office with that complaint. But men do.

I'd also imagine shy bladder syndrome is especially problematic for people who regularly undergo drug testing, right?

Yes. Yeah, and you know part of it is just like any social phobia, right? Once you have exposure to something — a negative response — your brain remembers. So you now have a trigger and any time that trigger comes up again, you already have a preconceived notion of what that response is going to be. It’s no different than being bitten by a spider or stung by a bee. The next time you see one, you have an instant fear response. The same wiring does this in your bladder where, if you have an issue one time, you can’t use the restroom and it can kind of perpetuate itself. And every time before you’re going to go to the restroom it gets to the point where you can [think about it] and it's ‘Oh no, I have to go to the bathroom — now I can’t go because it’s public.' And then you can’t go. People can associate it with things negatively in that way.

Any solution or recommended treatment?

If it’s really something happening a lot and affecting your ability to interact and go out in public and do things you’d like to do, then absolutely you should be checked out by somebody. Sometimes there can be related problems we’d want to check out, to make sure that everything else with the bladder and prostate itself is working OK and there’s nothing else going on — those cases are rare. But usually, that’s the first part of it. And then patients need to know this happens to a lot of men. There are small things we can do, such as scheduling what we call 'time voiding,' where you make a schedule for your urination throughout the day and if you coordinate it when you know you can be in private, that prevents you from being in the situation.

In extreme measures, we can teach men to self-catheterize when they're out — to empty their bladder — and can’t be in private. That certainly does work, but it’s obviously less than desirable for patients to have to do. We can also send you to a behavioral therapist and usually, through cognitive therapy and what’s called ‘graduated exposure therapy,’ we can condition someone to no longer respond in the same way to the same stimulus. There are definite treatment options.

Any particular age when it often starts?

No. Believe it or not, it can happen a lot — we see it a lot in adolescents or young children from the age of 5 and up. And as they start to potty train they can be susceptible to it. We often see it in younger kids. But you can not have it your whole life and all of a sudden develop it later in life. It spans the whole age range from childhood to adulthood.

Anything to add?

If you have it, realize you’re not alone. And there certainly are therapies to help if you have an extreme or very bothersome version of it, and it can definitely be fixed or improved.

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