Bashful and Overactive Bladder
In 2000, I published an article in the monthly “Ha-Refuah”, entitled: ‘Psychological treatment of Bashful Bladder”, which is called Paruresis in the literature. During that period, very few articles and research focused on this phenomenon, while recently there have been more such studies. Research shows that the bashful bladder syndrome is more common among men than it is among women. Its occurrence is in about 20% of the population. People who suffer from this phenomenon avoid going to public restrooms or to bathrooms at their friends’ houses. When the phenomenon is less severe, they are prepared to go to a public restroom and may even start to urinate, but when they are anxious about anyone entering the restroom, their bladder closes right away.
About 17% of the population have “overactive bladder”, they experience the urge to void at a frequent rate, even when the bladder is not full. In the professional literature, the bashful bladder is attributed to social anxiety, while the overactive bladder is attributed to physical problems or anxiety. There is no psychological explanation why stress and anxiety may cause these two symptoms.
Since I found that people with bashful or overactive bladder tend to be overly cautious, it is important to examine their level and their parents’ level of caution, with the help of a questionnaire
“Cautious vs Daring Self Test.”
I recommend reading the chapter entitled:
“Cautious vs Daring.”
For most of those suffering from bashful or overactive bladder, one of the parents tends toward cautious, while the other toward daring.
During the treatment of various anxiety symptoms, I tend to use the saying “Knowledge is power.” The goal is to explain to the patient why God or Nature planted all the anxiety symptoms in humans and even in large animals. An explanation given to the patient is that the symptoms of the bashful bladder and of the overactive bladder are like two computer programs in the brain, which contributed to the survival of prehistoric man, each according to the dangers lurking. A rapid emptying of the bladder, even if it was not full, helped prehistoric humans when they identified a preying animal in the distance which had not yet spotted them. Emptying of the bladder lightened the body weight during
"Fight or Flight."
Likewise, in case they were hit in the belly in the course of the battle, a full bladder could have been injured. The bashful bladder contributed in the event that they started to void when suddenly they spotted a preying animal approaching. Of course, they could not ask the animal to wait patiently until they finished voiding, and only then would they be free to fight or flee. The conclusion is that at a time of high anxiety, the bladder locks up immediately.
Modern Man, who suffers from social anxiety at a high level, feels vulnerable while voiding in a public place. He may fear being exposed to verbal criticism, or to negative thoughts others might think of him. Instinctively, the bladder closes up. If a person suffers from social anxiety at a lower level, it’s preferable to empty the bladder frequently. Unfortunately, this “computer program,” which facilitated survival for prehistoric man, disrupts the functionality of Modern Man.
It is important to emphasize to the patient that unfortunately it is not possible to delete from the brain the stress and anxiety “programs” which cause the phenomena of the bashful or the overactive bladders. He has to learn to “press a control button” on his "computer brain," in order to remove these outdated “programs” from his thoughts. When a patient learns this, it is easy to self-accept and to avoid self-criticism. As a result of this, his chances are greater to overcome the phenomenon more quickly.
I explain to the patient that all the body muscles are divided into voluntary muscles such as in the hands and feet, and involuntary muscles such as those of the heart or of the stomach. Sometimes it happens that voluntary muscles work without being willed by its owner, as in the case of contraction of facial muscles, which are called tics. The bladder muscles are voluntary muscles, but those suffering from this phenomenon have lost control over them in that the muscles open too frequently or close before completely voiding. Thus, it is important to teach the person to re-gain control over these muscles.
Steps in Gaining control over the Bashful Bladder
It is important to teach the patient relaxation methods, since all those suffering from this phenomenon experience stress and anxiety to a high degree. Sometimes, the anxieties stem from social anxiety, and other times, the stress stems from the anticipation that the bladder may close up again. The relaxation methods described on this website
"Deep Breathing"
and
"Muscle Relaxation"
should be practiced several times a day. Likewise, at least once a day, listen to one of my
"Relaxation Recordings."
Since positive imagery strengthens the implementation of various tasks, it is important, while being relaxed, to imagine positive coping with the problem afflicting the person: the ability to be relaxed while voiding in a public bathroom, or voiding only when the bladder is full.
Exercise Steps for Overcoming the Phenomena of Bashful Bladder and Overactive Bladder while being at home.
• Exercise several times daily the contraction and relaxation of bladder muscles, (while not urinating) with the intention of strengthening the bladder muscles and learning to regain control that had been lost over a voluntary muscle.
• Exercise several times a day, (while urinating) the opening and closing of the bladder, while smiling.
Exercise Steps for Overcoming the Phenomena of Bashful Bladder while being at a Public Restroom:
In the first stage, the goal is "not" to void, but, to practice the following steps:
• Standing in a closed toilet-stall. Practice opening and closing the bladder mussels while smiling. When you hear a person entering the bathroom, behave as if you finished. Leave the stall, wash your hands, and exit the restroom.
• For women, repeat the practice while sitting down.
• For men, repeat this step while the penis is outside the pants.
• For men, repeat this step at the urinal.
After the successful practice of the previous steps, it is important to exercise urinating in the following steps:
• Urinating in the closed stall, while the bathroom is empty of people.
• Urinating even when people are entering.
• For women, repeat the practice while sitting down.
• For men, urinating at the urinal, while no people are there.
• For men, urinating at the urinal while people are there.
I would be appreciative if people who have done these exercises would share this in an email describing the difficulties and successes. I would be glad to include your description on my website, completely anonymously, with the goal of enabling other people to benefit from the described experience.
Thank you,
Dr. Baruch Elitzur
Translation from Hebrew by Ruth A. Rin, www.AlefBetTranslation.com
Case Descriptions of Bashful Bladder
The three males who came under my care in the course of one year all complained of an almost identical disorder: an inability to urinate at a public urinal whenever another male was in proximity. When urinating in an enclosed stall in a public urinal, as soon as someone else entered the restroom their flow would stop. When urinating in their bathroom at home or at any other house, as soon as they heard noise from nearby - such as footsteps or the turning of a faucet - their flow would stop. These patients would struggle to urinate even in a place as "open" as a forest. Two of them developed methods for avoiding urination when in close proximity to others, but the need for isolation when urinating caused them distress. All three of the men noted that the problem began at a very young age. They could not recall any traumatic factor in the onset of the disorder. All three claimed that, apart from the problem of bashful bladder, they had adapted to daily living and enjoyed a sense of satisfaction - despite the fact that they considered themselves overly sensitive and lacking in assertiveness.
The first male, age 18, came to me for treatment because he feared the disorder would interfere with his adjustment to military reserve duty. The second male, age 24, came under pressure from his girlfriend because the disorder hindered them on outings with other couples. The third male, age 50, came for treatment because his hospitalization had forced him to need a catheter when he was unable to urinate using a bedside container. Faced with the prospect of a second hospitalization, he wished to avoid another catheter.
In the framework of short-term psychological treatment, one is aware of the great importance of explaining to the sufferer the root of their
disorder. The assumption is that "knowledge is power". When a patient understands the cause of a disorder, he is less angry and less disappointed with himself: For example, an accepted explanation for frequent urination when in a pressured situation relates it to an evolutionary advantage. During an emergency in the wild which stimulates the
"Fight or Flight"
response, urination reduces body weight. In addition, in the event of a wound in the region of the bladder, premature voiding tends to prevent its rupture. Since I was unable to find in the professional literature any explanation of an evolutionary advantage for urinary retention during an emergency, I was forced to postulate such an advantage.
The first five sessions with each patient, were conducted once a
week. The sixth, which was designated for feedback, was spaced at almost a month.
First and Second Sessions
After receiving information about the disorder and a psychological assessment of personality, each patient was given an evolutionary explanation of the disorder. Below is a reconstructed text of the directive:
"When God or Nature created humans and living creatures, there was planted in the brain a program which aimed to improve the chances of their
survival. We'll use as an example a deer standing in a forest and urinating. As soon as a lion appears opposite it, the deer is faced with three possible responses:
a. To politely ask the lion to wait until it is done urinating, and after that flee;
b. To continue urinating even while fleeing;
c. To stop the flow of urine and quickly flee. With disappearance of the danger, the flow of urine will return.
I assume you'll agree with me that the third possibility is the most logical. This is exactly what happens to you when you are urinating at a
public urinal. Since it is your character to be somewhat sensitive, in the subconscious you feel like a creature exposed to attack. When a strange person enters the restroom, or when you hear a noise nearby, the survival instinct causes the bladder to instantly close and your body moves to act in a state of
Fight or Flight.
The problem is that the survival instinct was implanted millions of years ago, when human life in the wild was established, and it hasn't been
revised since we came down from the trees. It may be compare to a computer built at the beginning of the computer age, on whose hard drive was burnt a specific program. Today the computer still processes well, but sometimes the old program appears on the screen and interferes. It is very difficult to delete an old program. I am a psychologist who specializes in "human computers." I will attempt to teach you, in a limited number of sessions, to delete the old program whenever you want to urinate in the presence of strangers.
Third Session
By means of metaphor, it was explained to each patient that their body is like a car that works in two gears: a tranquil gear and a stress gear. While in tranquil gear, each mechanism of the body works leisurely and muscle tension is low. When in stress gear, each mechanism of the body is alert, muscle tension increases and the bladder shuts down. They are going to learn techniques how to transfer their body from a stress to a tranquil one.
The patients were inducted into a state of relaxation via multi-varied techniques. While in this state, they were directed to imagine that they are at a public urinal urinating next to a stranger. In addition, each patient was instructed to evoke images concerning his individual problem. The first patient was instructed to imagine that he was urinating in an open field, alongside his buddy from the army. The second patient was directed to imagine that he was urinating while on an outing with his friend, and the third was instructed to imagine that he was urinating into a container while lying in his bed at the hospital.
Toward the end of the third session, an individual program was established which was scaled from the perspective of the problem. The patients
were instructed to practice it throughout the week. The goal of the program was to prevail over the avoidant response in situations that stimulate urinary retention. With the objective of diminishing expectations and preventing disappointments, it was emphasized to each patient that the purpose was not to urinate in public restrooms, but to practice "as if". For example: To enter a public restroom and stand before a urinal with his fly zipped. When a male enters to urinate, he should act as if he has just finished and then exit the room.
1. to perform a similar exercise with the fly open.
2. to perform a similar exercise with his penis visible.
3. to enter an enclosed stall in a public restroom and practice relaxation.
4. to perform a similar exercise with his trousers unfastened.
5. to enter a bathroom at home and have housemates make noise in an adjacent room.
Sixth Session
The sixth session, which was conducted about a month later, was used for follow-up and support for continuing the exercise.
Treatment Results
The two youngest patients were eager to practice both relaxation and the imagery between sessions. At the fourth session, both reported their
success at urinating in various places under various conditions. They described this as an intense experience such as they had not felt in years. At the sixth session, they reported that they no longer felt a need to continue the exercise.
The third patient reported more modest results. According to him, he felt more comfortable urinating in public places, but avoided entering
restrooms if others were there. The sixth session was conducted after his release from the second hospitalization. He reported feeling dependent on a catheter only for the first day in the hospital, when he was confined to bed; but when he was free to walk around the department, he was able to urinate in the restroom after practicing relaxation. Although he was not completely free of the disorder, he asked to discontinue treatment.
People, who avoid urinating at a public toilet, tend to have a cautious personality more than their peers. Since “knowledge is power”, it eases for self-acceptance and for positive coping with a bashful bladder, reading of the chapter
"Cautious vs. Daring" is recommended.