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Drug Information for Paruresis

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Revision Date:  July 22, 2005

INTRODUCTION
Current theory about paruresis indicates it includes a psychological inhibition about voiding that may lead to dysfunctional control of the bladder and its sphincters. If drugs can help, they will work in one of two ways: 1) by reducing fear or inhibition, often combined with general sedation and depression of the central nervous system; 2) by acting directly on the bladder and/or its sphincters via the autonomic (involuntary) nervous system. Therefore, the drugs listed below are given under two broad headings: Disinhibitors and Urological Medicines. Those are not necessarily pharmacological categories. A further category of drugs known to cause urine retention is given under Drugs To Avoid.  A few herbal supplements with known effects on physical or mental processes common to paruresis are listed under Herbal Remedies.  The purpose of providing this information is not to give advice on choosing a medication, rather it is intended to help you understand the effects drugs may have on your paruresis.  Once you know this information, it can be helpful in working with your doctor to choose medications appropriately if you need treatment for an unrelated condition, or as an aid in a doctor-supervised treatment program for your paruresis.  

Please note: This article is not medical advice.  It represents only the experience of certain individuals who have paruresis. Your medical doctor is the only one qualified to prescribe or suggest drug therapies which might be beneficial to you.  

There are no clinical studies indicating any drug is effective in treating paruresis if used alone.  Based on anecdotal evidence, IPA believes the best approach is to combine a drug with cognitive-behavioral therapy and/or support group work under a doctor's supervision.  

For more discussion of drugs, please see our Frequently-Asked Questions topic on medication, our Best of Board forum, or IPA Talk Forum.

Click one of the links below to jump to the section for these medications:  

             

DISINHIBITORS

Drugs in this group include barbiturate sedatives, benzodiazepine anxiolytics, antidepressants, and alcohol.   These substances act on the brain and central nervous system to produce sedation (barbiturates), relief of anxiety (anxiolytics, aka tranquilizers) or profound changes in brain function (antidepressants). Opiates such as codeine, morphine and heroin may also produce disinhibition but, as well as being dangerous, they are useless for paruresis because a physical side effect is they can cause urine retention.  Alcohol produces sedation and anxiety reduction as well as other, more complicated effects.  

  • Barbiturate sedatives

    Once the sleeping pills of choice, barbiturates now have very limited legitimate medical uses, mainly in the control of epilepsy and the induction of anesthesia.  

    Trade names: Nembutal, Seconal
    Advantages: Barbiturates reduce inhibitions. One contributor claims they work reliably for his BB in a way similar to alcohol, but without the hangover. 
    Disadvantages: Barbiturates are dangerous. They have high potential for addiction, with convulsions and risk of death in sudden unmanaged withdrawal. Even a minor overdose can depress the central nervous system to the point of coma and death. These drugs will show up on standard drug screening tests, so you must have a doctor's prescription if you intend to try them.
    Side effects: Coma, death, drowsiness, staggering, slurred speech.

  • Anxiolytics

    Otherwise known as tranquilizers, the anxiolytics belong to the benzodiazepine pharmaceutical family whose best-known example is Valium. 

    Trade names: Xanax, Valium, Librium, Klonopin 
    Advantages: Anxiolytics reduce anxiety, which may be a factor in paruresis.
    Disadvantages: Anxiolytics seem unlikely to reduce inhibition enough to allow those with severe paruresis to void. They may be helpful in less severe cases, but two contributors have mentioned that they seem to reduce the urge to void. As one wrote: "On Xanax, I am able to stand in front of any urinal and fall asleep. Can't pee, though." The anxiolytics may be habit-forming and require special care in order to wean oneself off of the drug. 
    Side effects: Drowsiness, aggravated by simultaneous consumption of alcohol.

  • Sedative hypnotics

    In the same family as the benzodiazepines, sedative hypnotics are stronger. Some are short-acting. They are the modern sleeping pills of choice and are often used pre-operatively. 

    Trade names: Rohypnol, Mogadon, Dormicum 
    Advantages: One contributor believes hypnotics (Dormicum in particular) produce enough disinhibition and mental dissociation to be helpful for paruresis. 
    Disadvantages: Hypnotics put you to sleep. Research suggests that short-acting benzodiazepines may be more habit-forming than the long-acting ones. 
    Side effects: Drowsiness, confusion, amnesia.

  • Antidepressants

    The antidepressants cause profound and little-understood changes in brain chemistry. Their therapeutic benefits for depression are notoriously idiosyncratic: what works for one person may make another's condition worse.  This is a complex subject which cannot be properly covered here. IPA has reports from a number of contributors who say antidepressants have helped their BB, particularly the SSRI class of these drugs.  Others say they have not helped at all.  If you are tempted by this route (particularly if you suffer from depression as well as BB) you should discuss all your options in depth with a doctor, preferably a good psychiatrist.  

    The antidepressants fall into three categories:
    Tricyclic antidepressants: Divided into two subclasses, sedative and stimulant.  Side-effects, particularly those involving the heart, can be serious. 
    Monoamine oxidase inhibitors ("MAOIs" or "MAO inhibitors"): Dangerous, even lethal, especially in combination with other drugs and even certain foodstuffs. Antidepressants in this category are thought by one or two contributors to have helped their BB. Be aware, however, that these dangerous drugs to be used ONLY with active medical supervision. Some drugs in this class been clinically proven to reduce social anxiety for some people.  
    Nardil is interesting though. It has been helpful for some social phobias, like test taking and public speaking and there are some mixed reports in the scientific literature with mixed claims concerning paruresis.  There is one report that a related drug, moclobomide, a reversible monoamine oxidase inhibitor (Nardil is not reversible) has been reported to help paruresis.
    Selective serotonin reuptake inhibitors (SSRIs): Prozac is the most famous example. SSRIs function by interfering with the availability in the brain of a fundamental neurotransmitter, serotonin. They are all the rage these days and are thought to have fewer hazards and side-effects than the other antidepressants. However, the full list of side effects and contraindications for Prozac alone runs to 12 pages. Some SSRIs have been clinically proven to reduce social anxiety for some people.  One SSRI that many people with paruresis report good results with is Paxil.  

    Trade names:  Prozac, Paxil, Zoloft, Lexapro, Celexa, Luvox (incomplete list)
    Advantages: Despite many possible side effects, most are minimal or can be addressed by changes in dosage or medication.  For most people, SSRI's are not habit-forming. It is possible to stop using these drugs after a long-term dosage schedule, especially if treatment includes cognitive-behavior therapy, support group work, or other forms of self-help work.  
    Disadvantages: Side effects can be significant for some people.  Cost of long-term use can be significant.  Some have a genetic makeup that renders these drugs ineffective.  Getting off of the drug can be difficult.  
    Side effects: Major ones include:  suicidal thoughts or behavior, especially at the start of treatment or when dosage is changed; stomach or intestinal bleeding; an allergic reaction (difficulty breathing; closing of the throat; swelling of the lips, tongue, or face; or hives); irregular heartbeat; low blood pressure (dizziness, weakness); high blood pressure (severe headache, blurred vision); unusual bleeding or bruising; fever or chills; headache; tremor, nervousness, or anxiety; nausea, diarrhea, dry mouth, or changes in appetite or weight; sleepiness or insomnia; sexual side effects.  This is an incomplete list; check each drug's product insert for more information.  

SSRIs must be used with caution in children and adolescents.  Below is an example of the "black box" warning that appears on the Effexor XR product insert.  Similar warnings appear on all SSRI's:  

Suicidality in Children and Adolescents 
Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders. Anyone considering the use of Effexor XR or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. Effexor XR is not approved for use in pediatric patients. (See WARNINGS and PRECAUTIONS, Pediatric Use.) Pooled analyses of short-term (4 to 16 weeks) placebo-controlled trials of 9 antidepressant drugs (SSRIs and others) in children and adolescents with major depressive disorder (MDD), obsessive compulsive disorder (OCD), or other psychiatric disorders (a total of 24 trials involving over 4400 patients) have revealed a greater risk of adverse events representing suicidal thinking or behavior (suicidality) during the first few months of treatment in those receiving antidepressants. The average risk of such events in patients receiving antidepressants was 4%, twice the placebo risk of 2%. No suicides occurred in these trials.

For Prozac users in particular, hyponatremia (low sodium level) has been reported.  A person with paruresis doing fluid loading for graduated exposure treatment needs to be particularly careful to include enough sodium in their fluid intake to avoid dangerously low sodium levels which could lead to a life-threatening condition.  

  • Alcohol (not recommended, but included for completeness)

    Advantages: Several contributors say alcohol can reduce their inhibitions to the point that they are able to void in uncomfortable situations. 
    Disadvantages: Alcohol is a diuretic, causing a greater rate of urine formation coupled with dehydration, which can be a danger for those sufferers whose avoidance behavior includes limiting fluid intake.  While working on graduated exposure therapy, some people have had a beer during an exposure session to reduce inhibitions and increase urine production.  If alcohol works for you, be sure to drink enough non-alcoholic liquid to avoid dehydration. It does not work for everyone.
    Side effects: You may be drunk after consuming enough alcohol to produce disinhibition.  Any drug that produces intoxication is too risky for treating a chronic condition such as paruresis. Alcohol can be addictive, and indeed many people who have come to IPA seeking treatment have reported alcoholism in their history. It can damage major organs such as the liver and brain and, in high doses, can cause coma and death.  Because of these risks, IPA does not recommend alcohol for treating paruresis.  See our FAQ topic on alcohol for more detailed information.  

UROLOGICAL MEDICINES

  • Alpha-adrenergic blockers (Hytrin, Flomax) 

    These drugs lower your blood pressure. They relax the smooth muscles of the prostate and bladder neck and may or may not help people with paruresis.  They are commonly prescribed for BPH (benign prostatic hypertrophy)
    BPH is an enlargement of the prostate gland which may lead to a weak urine stream, a feeling you can't empty your bladder completely, a feeling of delay when you start, a need to urinate often, or a feeling you must urinate right away. Some physicians apparently mistake avoidant paruresis for BPH and insist on prescribing Hytrin or Flomax.  For this reason, patients need to be aware the drug could be given to you based on an incomplete or incorrect diagnosis.  Alpha blockers can cause a sudden drop in blood pressure after the first dose! 

  • Bethanechol

    Bethanechol chloride is a parasympathetic nervous system stimulant.  It's administered routinely for postoperative urine retention.  Bethanechol is a drug which increases the contractility of the involuntary muscles in the bladder.  It increases urgency.  However, due to the nature of paruresis involving an inability to relax the urinary sphincter muscles, bethanechol may act on one part of the urinary system without doing anything about the other.  At least two people have tried this medication without positive results.  It may really be contraindicated for paruresis as it is contraindicated for patients with other forms of difficult voiding.  

DRUGS TO AVOID

Most antihistamines are related to a class of drugs used for anesthesia or sedation.  These drugs are anticholinergic* and can lead to urinary retention as a side effect.  

Any noradrenergic** medicine (e.g., Effexor, maybe Wellbutrin, Strattera) as well as anticholinergic medicines (many of which are also noradrenergic, e.g., tricyclics such as imipramine, clomipramine, nortriptyline or anticholinergic meds used to treat stomach problems) can cause urinary hesitancy as a side effect. 

In general, any drug listing urinary retention or hesitancy as a side effect should be used carefully or avoided if a person has paruresis.  

*anticholinergic:  opposing or blocking the physiological action of acetylcholine (a neurotransmitter)

**noradrenergic:  liberating, activated by, or involving norepinephrine in the transmission of nerve impulses.  Norepinephrine is both a neurotransmitter in the sympathetic nervous system and a precursor of epinephrine (adrenaline), a hormone released during the body's response to stress or fear.  

HERBAL REMEDIES

Several herbal remedies purport to have effects on one's mood or the urinary system.  While trying these remedies may provide positive results, IPA has not heard of any reports where they have been particularly helpful.  Once again, these substances should be tried only at your own risk under the advice of a doctor.  A common problem with herbal remedies is that the dosage isn't well controlled, so products from different manufacturers may have differing concentrations of the active substances.  Concentrations may also vary between batches from the same manufacturer.  

  • Kava-Kava

Kava-Kava is an extract of a root grown in Polynesia (Piper methysticum), that has relaxing properties.  It can reduce anxiety and make a person feel mildly euphoric.  However, this root also causes liver damage in people with a particular genetic makeup or with other conditions that affect the liver.  In March 2002, the US Food and Drug Administration warned persons who have liver damage or who are taking medications that impair liver function to check with a doctor before taking kava-kava.

  • St. John's Wort

St. John's Wort comes from the plant Hypericum perforatum and is another herbal supplement that influences mood.  There have been studies indicating it can relieve mild cases of depression or anxiety.  See Linde, Klaus et al. "St John's wort for depression--an overview and meta-analysis of randomised clinical trials." BMJ 1996;313:253-258 (3 August). <http://bmj.bmjjournals.com/cgi/content/full/313/7052/253>  

  • Saw Palmetto

Saw Palmetto comes from the partially-dried fruit of the plant Serenoa repens, the American dwarf palm tree.  It is commonly used to treat the symptoms of benign prostate hyperplasia (BPH, or enlarged prostate).  There has been some reported use of it in treating chronic prostatitis as well, but no controlled clinical studies.  See Di Silverio F, D'Eramo G, Lubrano C, Flammia GP, Sciarra A, Palma E, et al. "Evidence that Serenoa repens extract displays an antiestrogenic activity in prostatic tissue of benign prostatic hypertrophy patients." Eur Urol 1992;21:309-14.

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WARNING AND DISCLAIMER: This website is NOT a substitute for medical or legal advice and does not constitute the practice of law, medicine, psychiatry, clinical psychology, clinical social work, or any other mental health profession.  If you are having trouble urinating, you should always contact a physician since difficulty with voiding can be a symptom of a serious medical condition. We are a group of professional people and people who have suffered with paruresis. We have assembled a board and a board of advisors to help people cope with urinary dysfunction that has a psychological or social origin. On this website, we are NOT practicing medicine, psychiatry, clinical psychology, clinical social work or any other mental health profession. You should have your doctor evaluate your condition before diagnosing yourself, and seek the appropriate necessary mental health counseling if warranted. IPA, Inc. disclaims any and all legal liability whatsoever.