Paruresis: why can't I pee in public toilets?

Often, people have fears and phobias related to using the toilet that feel too embarrassing to talk about because they consider the problem silly or believe that no one else has the same problem.

Needing to use the toilet when out can feel traumatic for some people. Before leaving the house, they may check where the public toilets are. They may reduce their fluid intake and use the toilet at home before leaving to make sure their bladder is empty. They worry and feel anxious about going out and may avoid the journey just in case they need the toilet.

This seems extreme to many people. It might feel hard to understand, but many fears and phobias are illogical. However, many people experience difficulties peeing in public toilets and fail to get help until it starts to take over their lives and prevent them from doing the things they love.

This condition is called paruresis, but it is also known as shy bladder or bashful bladder.

What is paruresis?

Paruresis is a phobia related to using the toilet. A study by Kuoch et al. (2017) found that 2.4 -16.4% of the population can suffer from this problem. It can affect males and females of all ages and backgrounds, although males are more affected. The Diagnostic and Statistical Manual records it as a social phobia.

Paruresis makes people anxious; they might shake, feel sweaty, tense, and have negative thoughts about going out to social events, work-related events, or holidays because they fear they can't use public toilets. 

They might worry about sounds, smells, or difficulty starting to pee in a toilet, especially if other people are around, because they think people are listening and judging them.

Some people feel anxious about sitting on the toilet seat or touching the taps or doors because of germs. They may also fear having an accident and embarrassing themselves in public.

Paruresis can cause psychological distress, resulting in shame, embarrassment and stigma.

One of the first things people tend to do is avoid situations where they might need to use a public toilet. As a result, they prefer to go places they know and stay close to home. This can lead to refusing to stay at friends' houses and staying close to home, so there are no holidays either. Unfortunately, avoidance reinforces the fear, so the problem persists.

What treatments help paruresis? 

The first step to deal with this problem is to go and see your doctor to get a health check because any urinary infection or medical issues with urinating, such as prostate enlargement in males, need to be addressed first.

Sometimes doctors order tests to find out how much urine the bladder can hold; however, often there is no functional problem.

Many people find that they have no medical reason for their difficulties and realise that they are suffering from overwhelming anxiety. But there is hope to get past this problem with psychological intervention such as cognitive behavioural therapy (CBT), exposure therapy, and hypnotherapy.

How does CBT help?

CBT is a talking therapy where there is an emphasis on discussing how we think, feel and behave and how this impacts the body. Most of the emphasis is on the present rather than spending a lot of time talking about the past events that might have triggered this condition.

One technique CBT practitioners might use is exposure therapy. This is a process where the person is encouraged to confront their fear. This can be done by using a stepped approach to the fear of using public toilets. This will be discussed in session, sometimes using a ladder diagram to move the person's thoughts forward, step by step. Other times, the exposure therapy may happen between sessions. For example, one week they may just stand outside a public toilet; then, in future visits to that public toilet, they enter the cubicle and later actually use the toilet.

Sessions are usually weekly and will involve some tasks between sessions, such as completing thought logs. 6 -24 sessions are common, but some people may need more sessions.

How can hypnotherapy help?

Research suggests that hypnotherapy is effective for many kinds of anxiety through positive suggestions and relaxation. For example, a meta-analysis by Valentine et al. (2019) showed that hypnosis was effective at helping relieve anxiety. They also found that hypnosis was more effective when combined with other psychological treatments.

Nevertheless, there isn't a lot of research related explicitly to hypnosis and paruresis. Combining hypnosis, CBT, and self-hypnosis, therefore, provides a valuable treatment approach.

Hypnotherapy works by helping people to:

• relieve stress through relaxation;
• let go of past traumas;
• reframe difficulties with positive suggestions;
• desensitise the fear of peeing in a public toilet by doing imagined exposure;
• build confidence and self-esteem, and use all your resources to achieve your goals;
• imagine a positive future with the problem solved.

If you seek help from a hypnotherapist, you may also find that some are qualified CBT practitioners who can provide psychoeducation and combined treatment for a better outcome.

Book a consultation with a hypnotherapist to find out more.

References

Kuoch, K. L. J., Meyer, D., Austin, D. W., & Knowles, S. R. (2017). A systematic review of paruresis: Clinical implications and future directions. Journal of Psychosomatic Research, 98, 122–129. 

Valentine, K. E., Milling, L. S., Clark, L. J., & Moriarty, C. L. (2019). The Efficacy of Hypnosis as a Treatment for Anxiety: A Meta-Analysis. International Journal of Clinical and Experimental Hypnosis, 67(3), 336–363.