Drug Treatments for Paruresis

Drugs in this group include barbiturate sedatives, benzodiazepine anxiolytics, antidepressants, and alcohol. These substances act on the central nervous system to produce sedation with concomitant relief of anxiety (barbiturates and benzodiazepines), or more insidious changes in brain neurochemistry over a longer period of time (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 can produce sedation and anxiety reduction as well, however there are more deleterious effects which can also result from its use which would need to be taken into account.

Sedative-hypnotics – Barbiturates – 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 (they act in a manner similar to benzodiazepines – on the GABA receptors in the brain). 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 developing dependence, with risk of convulsions and 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.

Sedative-hypnotics – Benzodiazepines – Have been colloquially referred to in the past as “tranquilizers.”

Trade names: Xanax, Valium, Librium, Klonopin, Halcion, Restoril

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 (alcohol and benzodiazepines act on the same receptor in the brain – GABA; hence, simultaneous use can lead to additive sedative effects). Due to the risk of developing dependence with continued use, withdrawal can occur with sudden discontinuation, potentially leading to seizures and death. There is also a potential effect known as “paradoxical anxiolytics,” in which the drug actually causes worsening excitation and anxiety and opposed to anxiolysis and sedation; this occurs more commonly in the elderly.

There are also less known benzodiazepines which are used by many as sleep aids and are also seen used preoperatively. They are typically shorter-acting than the aforementioned benzodiazepines, however prolonged continuous use can lead to the same side effects.

Trade names: Rohypnol, Mogadon, Dormicum

Advantages: One contributor believes hypnotics (Dormicum in particular) produce enough anxiolytics and mental dissociation to be helpful for paruresis.

Disadvantages: Somnolence. Research suggests that short-acting benzodiazepines may be more habit-forming than the long-acting ones.

Side effects: Drowsiness, confusion, amnesia. See side effects listed above for benzodiazepines.

Antidrepessants – 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 four main categories:

1. Tricyclic antidepressants: these medications are commonly referred to as TCAs, and represent the oldest class of antidepressants.  As such, they have a number of side effects which need to be taken into account.  These include low blood pressure (due to alpha blockade), anticholinergic effects (which could aggravate the symptoms of paruresis), sedation (though this does not apply to all), cardiac arrhythmias (it is recommended to obtain a baseline EKG before starting TCAs to rule out a prolonged QT interval, which could predispose to arrhythmias), in addition to others.
Examples: amitriptyline, doxepin, clomipramine, protriptyline, nortriptyline.

2. Monoamine oxidase inhibitors (“MAOIs” or “MAO inhibitors”): Dangerous, even lethal, especially in combination with other drugs (particularly other antidepressants which act to increase levels of serotonin, a combination which could lead to a very dangerous clinical picture called serotonin syndrome) and even certain foodstuffs (there is a very long list of foods which, in combination with MAOIs, can lead to a hypertensive crisis due to their tyramine content). It is rarer to see physicians prescribe these medications nowadays due to the potential dangers.

Antidepressants in this category are thought by one or two contributors to have helped their paruresis. 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.

3. 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 (though it must be emphasized that there are differences in receptor profiles between the different SSRIs, and Paxil has actually been found to be the most anticholinergic of the class; thus, while potentially decreasing anxiety, it may promote urinary retention).

Trade names:  Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), Lexapro (escitalopram), Celexa (citalopram), Luvox (fluvoxamine) (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.  There is no consensus regarding the optimal time of use for these medications, and usage should always be coordinated with a physician.

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 – one should not abruptly discontinue these medications, as some of them can lead to very uncomfortable withdrawal symptoms.

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 (gastrointestinal side effects are the most frequently experienced); sleepiness or insomnia; sexual side effects (these can occur in around 40% of patients).  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 (an SNRI) 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 several SSRIs, hyponatremia (low sodium level) has been reported (this is due to a syndrome termed SIADH – syndrome of inappropriate antidiuretic hormone secretion); this is usually observed in elderly patients, though it can occur at any age. 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.

4. Serotonin and norepinephrine reuptake inhibitors (SNRIs): the 2 prototypes of this class are duloxetine (Cymbalta) and venlafaxine (Effexor). They have dual action on increasing the levels of norepinephrine and serotonin (and, at higher levels, of dopamine). They have similar efficacy to the other classes of antidepressants and usually exert their anxiolytic effect at higher doses (as the other classes do).

Advantages: Cymbalta has been recognized as an effective adjunct in patients who experience concomitant neuropathic pain in addition to their psychiatric symptoms. These drugs are usually well tolerated and are becoming more popular.

Disadvantages: the side effect profile does not differ significantly from the list outlined above for the SSRIs. Since there is an increase in norepinephrine levels, a dose-related increase in diastolic blood pressure has been observed, and should be monitored. Also, a withdrawal syndrome from venlafaxine has been described which can be very unpleasant. Physiologically, norepinephrine can act to increase contraction of the smooth urethral sphincter, therefore there is some risk associated with using these medications in terms of aggravating paruresis.

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 (it blocks release of antidiuretic hormone – ADH), 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 anxiolytic. 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 (irreversibly) 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.

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 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.

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. Due to its effects on serotonin, its combination with other antidepressants may result in serotonin syndrome, so caution is warranted. 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.