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Shining the spotlight on stage fright and shy bladder syndrome

In TENA’s 2018 public toilet survey, we discovered several intriguing stats including the colossal £2.2 billion that is spent by the UK every year on going to the loo when Brits are out and about. Another key stat which came to light though was that 25% of respondents experienced stage fright after paying to use a public toilet.

But when does an occasional sense of stage fright turn into the longer lasting condition of shy bladder syndrome (formally known as paruresis) – “an inability to urinate in the presence, real or perceived, of others” as it is described by the UK Paruresis Trust (UKPT). 
 
We spoke to Andrew Smith, Chair of Trustees, to talk more about the condition and discuss the potential parallels with urinary incontinence.

Do you believe that that there is a stigma attached to paruresis? If so, what are the main ways in which you think this could be overcome?

We talk of primary and secondary paruresis: primary is the fact of not being able to pee in social situations; secondary is what you make of it. There are some who find they can’t pee, but make nothing of it and will say to others it has happened. 
 
But for the men and women we deal with it is a shameful, humiliating or embarrassing condition. Hence they keep it secret. The men especially feel they cannot be seen to have a weakness, and feel that if they disclose it, they will be teased or taunted. 
 
We help them overcome this in our workshops. They meet a small group of other men who all look normal, and who lead normal lives. So we normalise it for them, and make them aware that they are on a spectrum of ability or inability. 
When we enable them to visit public toilets, they notice other men preferring to use cubicles, or avoiding standing immediately next to others. This makes them feel better about themselves. 
 
We have a comprehensive list of issues we educate them about, which all chip away at their false beliefs.
 
We encourage them to tell those who need to know and whom they trust; the feedback of such disclosures is invariably positive, and takes a weight off their shoulders, as they no longer need to live a pretence.

Do you think there is an issue with paruresis being effectively diagnosed by health professionals?

Yes, in the case of GPs and urologists. A GP’s reaction seems to be a lottery: their feedback could be any of the following:
 
• “You’d be surprised how many people come to me with this problem”
• “Just use a cubicle”
• Bafflement
• Laughter
• Prescribing anti-anxiety medication
 
Meanwhile, urologists are focused on the physical body and when no physical obstruction is found, they tell the client there is nothing wrong with him!
 
At least clinical psychologists recognise it as a social anxiety and so are able to treat it in a standard way.

If you took urinals out of the equation – do you think that paruresis would affect men and women equally?

For convenience we put sufferers (often called Avoidant Paruretics – or abbreviated to APs) into one of three categories:
 
• Severe: struggle in domestic situations
• Intermediate: can usually manage domestic situations, but struggle with cubicles
• Mild: can usually manage cubicles, but struggle with urinals
 
So if urinals did not exist, men and women would be affected equally.

In general, do you think that most business toilets e.g. pubs, restaurants etc., or public loos are accessible to people who suffer from paruresis?

No, they are not. An architect told me that toilet design is the lowest status job and gets lowest priority for money and floor space.  People like their personal space, but the spacing of urinals usually places people in each other’s personal space. 
 
Secondly, the visual privacy for an individual actually peeing is rarely met i.e. the lack of sight screens between urinals. Thirdly, for evolutionary reasons, people feel uncomfortable if there is activity immediately behind them, but toilets often have wash bowls and hand dryers placed opposite urinals. 
 
As for cubicles, gaps below doors and walls, or even up the sides of doors reduce personal privacy. Understandably, if the designer has no problem, they will not take these factors into account. But if they do, someone will question the extra cost, and will probably deprecate the attempt to provide a good design.

From your understanding, do you believe that urinary incontinence and paruresis are similar conditions in the sense that people can feel that their lives are restricted?

In the sense that lives are restricted: absolutely. We find examples of men retreating to self-employment so as to have total control of their daily routine. A self-employed man can go home at lunchtime, or even use a bucket in the back of his van as a toilet. 
 
People drop out of circulation: they turn down social invitations and refuse promotions or new employment when they find the toilets in the new location unmanageable. Others drop out of university – one young man was about to commit suicide because he had no life left to live. 
 
There are examples of a father sending his family on holiday without him and blaming work, due to an inability to use plane toilets. One man never married his partner because he could not face the problems caused by the wedding reception. The list goes on and on…
 
If you have read this thinking that you may well be affected by shy bladder syndrome, then have a look at the UKPT’s pointers as to how you can take charge of the charge of the condition. Or if you are concerned about involuntary leakage when out and about, a good first step is to look at TENA’s guide to understanding urinary incontinence in adults. 
 
Either way, it is important to remember that with the right help and advice, both conditions are manageable in daily life.