Paruresis (Shy Bladder Syndrome)

Anxiety

Dec 28

Written By Turning Point Psychological Services

For a very long time, Alex didn’t think of it as a problem, but now, looking back, he realises the signs have been there for a while.

Alex could pee at home without any effort. At work, he would usually wait until the bathroom was empty. If there was another person there, it took Alex slightly longer to initiate peeing as he felt a bit self-conscious, but he didn’t think much of it.

One day, Alex went to a crowded restroom at a restaurant over his lunch break. There were people waiting to use the urinals. Alex suddenly felt rushed, watched, and under pressure. He tried to pee quickly, but was unable to produce any stream. He left the restroom feeling humiliated and sensing what seemed like mocking and disapproving stares.

After that, he started paying attention, doing whatever he could to avoid being in this position again.

He began timing when he drank water, which gradually led to increasingly restricting his fluid intake. Choosing certain bathrooms over others. Peeing “just in case” whenever he had access to a “safe” restroom. Switching from urinals to stalls because they felt safer. He discovered that it was easier to pee when sitting on a toilet than when standing while using a urinal. But still, if someone walked in, his body locked up. Alex tried to relax and to wait, but the more he tried, the more difficult it was to produce the stream. He would sometimes leave the bathroom, walk around for a few minutes, and come back to try again.

Over time, the problem spread. Bathrooms that used to be fine stopped working. Even stalls felt impossible if there was any chance that someone could be waiting. Airports, planes, and road trips became a nightmare and he would decline travel whenever possible. Alex consumed less and less fluid during the day, stopped drinking any caffeinated beverages, and avoided situations where bathrooms felt unpredictable. He held urine for increasingly prolonged periods, often ignoring physical discomfort.

Now the anxiety started long before he even entered the restroom. Even the thought of a public bathroom became a trigger, often hours before he would actually need to go. He made sure to mentally map “safe bathrooms” in advance to be prepared and would detour significantly out of his way just to reach one. He sometimes used a single-occupancy, lockable bathroom in a hotel 20 minutes walking distance from his work (which was a hit or miss as somebody could potentially be lining up outside the door and Alex had no way of knowing that).

The bathroom in Maya’s university apartment that she shared with her roommates was just outside the living room. Maya, a first-year university student, had no difficulty using it to pee when she was alone in the apartment or when her roommates were watching a movie. The problems started when it was quiet in the apartment and her roommates were nearby. Maya would try to use the bathroom to pee but felt pressured, as she felt her roommates might be wondering why it was taking her so long. The more pressured she felt, the more difficult it was to produce the stream.

This became even more challenging in the mornings, as Maya knew that her roommates would be waiting to use the bathroom. She peed while taking the shower with no problem. But on the mornings when she didn’t have time to shower, she would still have the water on, and it really helped.

Public restrooms at university were harder. She couldn’t have water run there, and she could not handle the lines and the thin walls between the stalls.

Maya started adjusting. She avoided drinking any fluids before going to school and stopped carrying her water bottle. Peed “just in case,” when she had an opportunity, even when she didn’t really need to. She learned she could sometimes force it by straining or squeezing, even though it felt uncomfortable. She learned which positions were more likely to lead to successful urination and became over-reliant on positions and breathing patterns. When it worked, she told herself she’d found a solution, but then, when it didn’t, she felt defeated.

When she heard people lining up outside talking, she wondered if they were discussing her. When there was silence outside, she interpreted it as scrutiny.

To escape after fruitless attempts to urinate, Maya would wait for a hand dryer to activate or some other external noise, flush the toilet, and exit pretending to be on her phone to avoid other women’s gazes. She wondered if people waiting in line knew that something was wrong with her and were secretly judging her. She often noticed the girls in the line giving each other a look and a smile, and she was sure they knew. Shame and humiliation stayed with her for a long time. Sometimes the feeling lingered for hours or even the rest of the day.

Maya was also dreading the next uni class, knowing that her bladder was full. This made her fluid restriction even more severe.

Maya left events early. Avoided trips. She panicked before long drives and began structuring outings around where and when she might be able to pee. She said no to things she actually wanted to do. Bathrooms stopped being neutral places and became obstacles she had to manage. Sometimes alcohol helped her pee, but other times it made things worse.

Maya started wondering if something was physically wrong. She finally went to see a doctor, but her UTI test came back negative, and the doctor told her to just relax.

Book

Contact

What is Paruresis (Shy Bladder Syndrome)

Paruresis, also known as shy bladder syndrome, is a form of social anxiety that shows up as difficulty urinating when other people are nearby or could be nearby. A person with paruresis can urinate without any difficulty when alone at home, but may struggle in public restrooms and in situations where somebody could hear, see, or be waiting.

Paruresis can look different from person to person. For some, it shows up as a delay or hesitation before the stream starts. For others, it can feel like a complete shutdown. Some people struggle only in certain places, while others find the difficulty spreads over time to more and more situations.

A common misunderstanding is that paruresis is a fear of urinating in front of others. But in reality, the core fear is usually about not being able to urinate when others are nearby.

Main triggers of paruresis include public restrooms where other people may be present, feeling rushed, anxiety about being unable to produce a stream or producing a very weak stream, and worry about being judged for how long it takes. Factors such as silence, thin walls between stalls, or a lineup outside the washroom may further increase anxiety.

Paruresis usually worsens with time. In an effort to cope, people start adjusting what they drink, where they go, and how they use the bathroom. These strategies can reduce anxiety in the moment, but over time they reinforce the problem and allow it to spread to more and more situations.

Common safety and avoidance behaviours of people with paruresis include:

· Restricting fluid intake (which makes urination even harder)

· Peeing “just in case” whenever a familiar or “safe” bathroom is available

· Trying to identify and use only “safer” bathrooms

· Avoiding urinals and relying only on stalls, or only specific stalls

· Avoiding travel, long meetings, events, or social plans

· Leaving events early

· Declining invitations that involve travel, lines, or time pressure

· Planning routes and days around available bathrooms rather than activities

· Running water, flushing early, or waiting for hand dryers to create cover noise

· Using specific body positions or breathing patterns believed to make it easier

· Straining, squeezing, or forcing the stream

· Holding urine for long periods

· Using alcohol

Although these strategies feel necessary, they gradually narrow the range of situations in which urination feels possible, making paruresis generalize to additional situations.

How to Rule Out a Medical Cause of Paruresis

There are some tests that may be indicated to rule out medical conditions such as a urinary tract infection (UTI), cystitis, or an enlarged prostate.

But, if you have no difficulty urinating when you are alone at home, while struggling when other people may be nearby, it’s probably paruresis.

Paruresis Treatment

The most effective treatment for paruresis is graduated exposure therapy. In our clinic, we find that combining graduated exposure with ACT (Acceptance and Commitment Therapy), makes the treatment even more effective.

Treatment includes creating a clear plan – a hierarchy - to gradually attempt to urinate in different situations starting with those that feel the least challenging and progressively increasing difficulty over time. Treatment also includes fluid loading before exposure practice. This is done to increase the urge to urinate, making initiating a stream easier.

A typical paruresis reatment plan may include:

· Assessment of how paruresis developed, how it changed over time, and what currently triggers it (both internal and external).

· Identifying current overt and covert safety and avoidance behaviours.

· Psychoeducation about paruresis, including how safety and avoidance behaviours maintain it, and how fluid loading is used in treatment.

· Learning ACT-based strategies to support motivation, willingness, persistence during exposure practice.

· Creating a personalised exposure hierarchy.

· Identifying a reliable backup restroom for early exposure work.

· When possible, recruiting a pee buddy – a trusted person who can support exposure practice.

· Fluid loading prior to exposure.

· Practicing exposure tasks between sessions, reviewing progress, and adjusting strategies as needed.

Why Paruresis Is Often Missed or Misunderstood

Paruresis is very common, but is underdiagnosed because:

· People are embarrassed to talk about it

· Many assume it’s a quirky habit or a personal flaw and don’t realize it’s a known and treatable psychological condition

· Even if a person seeks help, health professionals may not recognise paruresis. People are often referred for medical tests that come back normal, without further explanation

Even when a mental health professional recognizes that this is an anxiety disorder, one key misunderstanding often remains: assuming that the person is fearful of urinating in the presence of others. The treatment (usually Cognitive Behavioural Therapy (CBT)) based on this assumption may include exposure exercises that miss the real fear, leading to little improvement. This leads to a lot of confusion and despair.

The problem is subtle but important: in most cases, the fear is not about urinating in the presence of others. It’s about NOT being able to urinate when others might be nearby. This nuance changes how exposure is planned and what the person is actually practicing. For this reason, it is important to work with a therapist who has specific knowledge and experience treating paruresis rather than treating it as generic social anxiety.

If parts of this felt uncomfortably recognisable, there’s nothing unusual or “wrong” about you. Paruresis follows a very consistent pattern, even though it can feel deeply personal and isolating when you’re living with it.

What keeps shy bladder going is not the bladder itself, but the way anxiety, pressure, and well-intended coping strategies interact over time.

Many people feel a sense of relief when they finally recognise their own experience in this pattern. Paruresis can feel deeply personal and isolating, but it is surprisingly consistent in how it develops and how it responds to treatment.

The encouraging part is that this also makes it very treatable. People often see meaningful improvement once the pattern is properly understood and addressed — even if they’ve been struggling for years.

For people who want support, working with a therapist who has specific experience treating anxiety disorders and paruresis in particular, can make the process more effective and straightforward.

Book

Contact

Frequently Asked Questions About Paruresis

Yes. Paruresis is commonly referred to as shy bladder syndrome. Some people also call it bashful bladder or pee anxiety.
Paruresis is not caused by a bladder disease or obstruction. It is a form of anxiety that affects the ability to urinate in certain situations, despite normal bladder function.
This pattern is very typical of paruresis. The difficulty is triggered by pressure, awareness of others, or the possibility of being heard or observed — not by the bladder itself.
It can help temporarily. But over time, these strategies make paruresis more entrenched by teaching the body that urination is only possible under very specific conditions.
It often does. As people rely more on avoidance and safety strategies, the difficulty can spread to more situations.
Graduated exposure therapy is considered the most effective treatment. Many people benefit from combining it with Acceptance and Commitment Therapy (ACT).
No. Many people improve without identifying a single cause. Treatment focuses on changing the current pattern, not uncovering a past event.
Yes. People often see meaningful improvement once the pattern is properly understood and addressed, even after struggling for a long time.

Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.