Shy Bladder Syndrome

That is a large proportion for a condition most people have never heard named, and it is the only prevalence figure in the material.

Why the law had to notice paruresis

The consequence of being unable to urinate on demand, in front of an observer, is that a person cannot pass a supervised drug test. Institutions that require such tests have therefore been forced to decide whether the condition is real.

In the United Kingdom, paruresis is catered for in the rules for mandatory urine testing in prisons, and guidance for testing people on probation has cited it since 1 August 2005 as a valid reason for failure to produce a sample that is not to be construed as refusal. It appears in the NHS-approved Healthinote Directory, a person whose ability to work is limited by it may be eligible for Universal Credit, and it is reported to have been accepted as grounds for excusal from jury service.

The United States Bureau of Prisons starts from the opposite presumption. Its regulations provide that an inmate is presumed unwilling if they fail to provide a sample within the allotted time, and may rebut that presumption during the disciplinary process. Program Statement 6060.08 allows the two-hour window to be extended for a documented medical or psychological problem, and permits indirect supervision, such as a secure dry room after a thorough search.

American courts have ruled that failing to treat a properly diagnosed case might violate a prisoner's constitutional rights, and have routinely rejected unsubstantiated attempts to invoke it against a failed drug test, particularly without medical records or physician testimony. The International Paruresis Association's advice follows from that directly: documentation matters, because a person who cannot produce a sample is presumed guilty in the absence of evidence.

Florida, Massachusetts, Maryland, Michigan, New York and Tennessee have modified their prison drug testing regulations to accommodate it. Some prisons offer a dry cell, a cell with no plumbing and only a container, as an accommodation.

Why no test can confirm or refute paruresis

The Handbook of Correctional Mental Health states the position plainly: no definitive or objective test exists to confirm or refute paruresis, and neither the absence of prior treatment nor the ability to void in some social situations and not others rules it out.

It also names the intervention that must not be used. Coercive approaches such as forcing fluids while observing somebody with paruresis are ineffective and can cause serious medical complications. The alternatives it lists are:

• unobserved collection in a dry room
• hair testing
• sweat testing with a patch
• blood testing

Its argument for them is pragmatic rather than sympathetic: they remove the need for futile attempts to distinguish genuine cases from fabricated ones.

What happens physically during paruresis

The mechanism appears to be a tightening of the sphincter or bladder neck through a sympathetic nervous system response, with the adrenaline surge probably involving both peripheral and central nervous systems.

The candidates are:

• the internal urethral sphincter, which is smooth muscle
• the external urethral sphincter, which is striated
• the levator ani, and particularly the pubococcygeus
• some combination of those

Inhibition of the detrusor command through a reflex pathway is possible. The pontine micturition centre, Barrington's nucleus, may also be involved, since inhibiting it relaxes the detrusor and prevents the internal sphincter from relaxing.

Two observations support the anxiety account without needing any of that detail. Paruresis tends to disappear under anxiolytics or when the person is otherwise disinhibited. And it is common among people who underwent a voiding cystourethrography in childhood, which is a procedure requiring a child to urinate while being watched and imaged.

How the DSM came to name paruresis

DSM-IV-TR described it in section 300.23 as performance fears about using a public restroom without naming it. DSM-5 names it, and classifies it as a social anxiety disorder. Kaplan and Sadock's Synopsis of Psychiatry lists urinating in a public lavatory alongside public speaking as a situation people with social phobia fear.

It goes beyond shyness or embarrassment. Some people cannot urinate in a moving vehicle, or become fixated on the sound of their own urination in a quiet building. In severe cases a person can urinate only when alone at home, or by catheterisation.

Parcopresis, or shy bowel, is the equivalent condition for defecation.

How paruresis is treated

Systematic desensitisation here has an unusually concrete procedure. A trusted person stands outside the lavatory at first, and once that is tolerated moves closer, in stages. Cognitive behavioural therapy is used alongside it to move the person's self-description from somebody who cannot urinate to somebody who can, or who is not excessively frightened when they cannot.

The American Urological Association recognises the condition and lists it in its directory. In the United Kingdom, NICE guidelines for social anxiety disorders cover its recognition, assessment and treatment.