Paruresis or Shy Bladder Syndrome: An Unknown Urologic Malady?

Steven Soifer; Greg Nicaise; Michael Chancellor; David Gordon

Disclosures

Urol Nurs. 2009;29(2):87-94. 

In This Article

Defining Paruresis

For the purpose of this article, paruresis is defined as:

After an initial unpleasant experience, the individual anticipates difficulty urinating whenever entering a lavatory. Forcible attempts to control the process fail, and associated anxiety with performance reduces the individual's chances of voiding while in a public facility. The paruretic must then adjust to the disorder by voiding as much as possible when at home, restricting the intake of fluids, locating vacant public rest rooms, running the tap, and refusing extended social invitations (Zgourides, 1987, pp. 1171-1172).

In addition, patients with paruresis ("paruretics") frequently describe a sensation of a "freezing" or "locking up" of the bladder. To date, our best understanding of this phenomenon is that there is a tightening of the sphincter and/or bladder neck due to a sympathetic nervous system response. The "adrenaline" rush that produces the involuntary nervous system response probably has peripheral and central nervous system involvement, though the exact mechanism is unclear. In the absence of research and information, it is uncertain whether the offending muscle in males is the internal sphincter (smooth muscle tissue) or the external sphincter (striated muscle), levator ani (especially the pubococcygeus) muscle area, or some combination of the above. To further complicate matters, it is possible that there is an inhibition of the detrusor command through a reflex pathway as well. Finally, the pontine micturition center (Barrington's nucleus) may be involved, as its inhibition results in relaxation of the detrusor and prevents the relaxation of the internal sphincter.

Given the evolving understanding of the condition, it behooves health care providers to not only become more aware and educated about paruresis but also begin playing an active role in understanding the pathophysiology of the condition. It is important that all health care providers begin screening for paruresis so there is a better understanding of the incidence and effect of the disorder. One urologist estimated that one-third of his patients could not give urine samples in the office when requested. Many patients had to go home and bring their urine specimens back at a later date. This could indicate there is a significant problem that is not being reported or is being ignored.

It should also be noted that after surgery, many patients cannot be sent home from the outpatient recovery area until they are able to urinate. This is a huge problem for individuals with paruresis that is often compounded by the anesthetics used during the surgical procedure, as well as by the side effects of postoperative pain medications that may be prescribed. These authors have case reports of patients who have developed paruresis after post-op experiences.

Health care providers have a unique opportunity to assume a vital role in defining, screening, diagnosing, and treating paruresis. By seeing it only as a psychological condition, most urologists have, until now, made a Rylean category mistake (Ryle, 1949). However, by seeing it more as a duality, as both a psychological and a physical condition, much progress can be made in helping those afflicted by this disorder.

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