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why don't I pee when I want to? what is stopping it?

This description is a simplified version of the mechanism. The nervous system comprises one part that looks after voluntary actions e.g. raising your arm, and a second part that looks after actions you do not consciously control e.g. breathing when you are asleep, the body's preparation for fleeing danger etc.

The bladder is surrounded by muscle fibre called the detrusor. The tube that empties the bladder is called the urethra and it exits via the internal sphincter (think of a tap). The detrusor and the internal sphincter are not under your voluntary control, but under "unconscious" control.

The urethra then goes through the external sphincter, which IS under your voluntary control.

What is supposed to happen is that the bladder fills up and at a certain point sends a signal to say "time to empty". The unconscious mechanism triggers the detrusor muscle to squeeze the bladder in order to force out the urine - think of compressing a small balloon in your hands. At the same time the internal sphincter opens. The only thing stopping you from wetting your pants is your voluntary control of the external sphincter which you keep closed. When conditions are right, you consciously "let go" which opens the external sphincter and you pee.

With paruresis, the environment you are in causes your brain to go into an alert state i.e. it thinks there is a danger somewhere. The brain's action is to trigger the "freeze" response whereby the unconscious mechanism relaxes the detrusor muscle, and closes the internal sphincter. Hence even if you voluntarily want to pee, the unconscious is saying "wait, there's something wrong". So it does not help to be made to drink more and more in an attempt to force you to pee. The unconscious has shut the internal sphincter and the detrusor is not squeezing the bladder and so nothing will happen.

This is in contrast to a non-paruretic who, say, is trying to avoid giving a sample. In that case the detrusor is squeezing, the internal sphincter is open, and it is only the conscious desire to not pee that is keeping the external sphincter closed. Being forced to drink more and more increases the pressure of the urine against the external sphincter and eventually the person will be unable to hold it back.


Does hypnosis work?

The UKPT very cautious about hypnosis as a treatment for paruresis for two reasons:

1. We get people on our workshops who have tried hypnosis at some cost to no avail, and in some cases it has been a painful experience
2. Our honorary advisor, a chartered psychologist, who was also a registered psychotherapist and a hypnotherapist, told us hypnosis was not the treatment for this condition.Another clinical psychologist who works
with us says the same.

Avoidant Paruresis comprises two elements: primary and secondary.

Primary paruresis is the state of not being able to urinate in a social situation.

Secondary paruresis is what the individual makes of his or her primary paruresis i.e. loss of self-esteem and self-confidence, the feeling of being a unique freak, and depression.

The UKPT deals in the main with people who have both primary and secondary paruresis. The recognised treatment is Cognitive Behaviour Therapy (CBT).
The Primary is dealt with by graduated exposure: as in standard phobia desensitisation. The secondary is dealt with by cognitive therapy: this has to deal with proving to the patient that he or she is not a unique freak, but is one of a population of like patients who are normal functioning members of society; then the standard approach of establishing the patient's illogical views of reality is addressed and talked through.

Neither graduated exposure, or cognitive therapy will work on its own. Instead experience shows that incremental improvements in the one feedback positively into the other, and vice versa.

Given this, it is difficult to see how hypnotherapy can work effectively for such cases.

However, there are possibly people with only primary paruresis: who see it as a mechanical "fault", and are not shy of asking for treatment. In such cases, using hypnotherapy to teach relaxation and virtual desensitisation, may be effective.

The UKPT is interested in any evidence of the effectiveness of hypnotherapy. However previous approaches have claimed success without being able to provide any evidence of success, whether short or long term. The UKPT would be looking for evidence similar to that provided as unsolicited testimonials from participants at its workshops.


what is self catheterisation?

Self Cathing is the use of medically available Catheters (small plastic tubes) that can be inserted up the length of the urethra and give immediate mechanical relief to the problem. So far, it's the only sure fire way of peeing we know, and we are generally committed in the UK to getting to grips with this technique. Note: If you reach the conclusion that you want to have the option to self-catheterise, visit your GP and ask to be shown how to do it. Your GP can also prescribe catheters. Take along UKPT literature, or prints from the website to help you.

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