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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.
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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.
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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.
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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.
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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.
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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
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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!
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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 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 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 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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