The fear of urinating or paruresis is a type of phobia in which the patient cannot urinate in the real or imagined presence of other people, such as in a public bathroom. The analogous condition that affects defecation is called parcopresis.
It appears that paruresis involves a narrowing of the sphincter and / or bladder neck due to a response from the sympathetic nervous system. The adrenaline rush produced by the involuntary response of the nervous system probably involves the central and peripheral nervous system.
The internal urethral sphincter (smooth muscle tissue) or external urethral sphincter (striated muscle), the muscular area of the levator ani (especially the pubococcygeus), or some combination of the above, may be involved. It is possible that there is also an inhibition of the detrusor command through a reflex pathway.
The pontine voiding center (Barrington nucleus) may also be involved, as its inhibition results in relaxation of the detrusor and prevents relaxation of the internal sphincter.
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One possible cause of paruresis is having a voiding cystourethrogram (VCUG) in the past. “Complications that can occur in both sexes include UTI, hematuria, cystitis, as well as urinary dysfunction after catheterization, urination phobia, nocturia, and cessation of urination. In the literature, the psychological trauma resulting from VCUG was considered the same as that of violent rape, especially in girls ”.
Paruresis was described in section 300.23 of the DSM-IV-TR as “performance fears … using a public toilet” but was not mentioned by name. The current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) mentions paruresis by name.
The Kaplan & Sadock Synopsis of Psychiatry states : “People with social phobias (also called social anxiety disorder ) have excessive fears of humiliation or shame in various social settings, such as public speaking, urinating in a public toilet (also called bladder shy), and talk to a partner.
“The Synopsis describes the shy bladder as ‘inability to urinate in a public toilet’ and notes that relaxation exercises are an application of behavioral therapy to treat this disorder. Some people with paralysis experience delayed urination and must wait until they need to urinate to overcome their anxiety , while others are unable to urinate at all.
Context and urine samples
Observed urine tests can be problematic for people with paruresis.
There can be serious difficulties with workplace drug testing that insists on observed urine samples, if the testing regimen does not recognize and address the condition. In the UK, employees have a general right not to be unfairly fired and therefore have a defensible defense should this occur, but this is not the case everywhere.
There is mounting evidence to suggest that some drug testing authorities find paruresis a nuisance, and some implement “shy bladder procedures” that pay no more than word of mouth support for the condition, and where there is no evidence of they have carried out a real investigation into the matter.
An inmate may rebut this presumption during the disciplinary process. ‘ Although US courts have ruled that failure to treat properly diagnosed paruresis could violate inmates’ constitutional rights, courts have also “consistently rejected suspicious or unfounded attempts to invoke it in defense of the lack of drug testing. ‘, Particularly when there were no medical records or medical testimony to support the claim that it was paruresis.
Treatment for fear of urination
In terms of treating the mental aspect of paruresis, such treatment can be achieved through graded exposure therapy and cognitive behavioral therapy. In graded exposure therapy, the subject has a trusted person standing outside the bathroom at the beginning, and once the fear is overcome, the observer approaches, until step by step the phobia is overcome.
Gradual exposure therapy, cognitive behavioral therapy is used to change the patient’s mental focus towards the condition, from a person who cannot urinate to a person who can urinate or who is not overly afraid when unable to urinate in public.
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