Our Greatest Wealth Is Health

OCD Behaviors and the Urogenital Tract

May 18, 2024

Andrew Siegel MD 5/18/2024

A considerable share of my practice of urology is the evaluation and management of “urological-psychological” (“uropsych”) issues. Today’s entry discusses OCD (obsessive compulsive disorder) type behaviors that are focused on the urinary and genital tracts. A shout-out to my brilliant daughter Isabelle — entering her fourth year of graduate school and well on her way to receiving a doctorate in psychology with a specific focus on anxiety and OCD — who assisted me in this entry. (I do not state that she is brilliant because she is my daughter, simply because she has that amazing combination of being whip-smart, extremely hard working, and truly passionate about her work.)

OCD is a mental health disorder characterized by persistent obsessions — unwelcome and intrusive thoughts, urges, or images — that induce compulsions — efforts to suppress and neutralize the consequent anxiety and distress with ritual thoughts or actions.

In addition to unwelcome or intrusive thoughts, urges, or images, genuine physical sensations may also incite compulsions. These physical sensations may originate from any part of the body and are often perceived as uncomfortable or painful, causing distress, fear, and concern. Since these sensations are actual feelings, they are often given immediate validity and are regarded as being serious and consequential, when the truth of the matter is that they are often neither serious nor consequential (of course there are exceptions to this).

Because of the ample physical sensations generated by the bladder and gastrointestinal tract, they are particularly convenient vehicles for providing the perceptions that can spark compulsive behaviors. The urogenital tract (the urinary and genital systems) — the systems under the domain of urology — provides rich fodder in terms of both physical sensations as well as for a great range of genital anatomical variations that may provoke reactive compulsions. The subtype of OCD in which symptoms and compulsions are related to body functions is known as somatic OCD.

As a urologist, I not uncommonly see patients whose issue I classify as a urinary or genital OCD or at least a forme fruste – an incomplete manifestation – of OCD. I am not a psychologist (although I was just one course short of a dual second major in psychology in college) and am not sure if these patients meet strict DSM-5 criteria for OCD, but I am sure that they certainly display OCD-like behavior and that their underlying pathophysiology is more psychological than physical. In the words of Bill Maher: “I don’t know it for a fact, I just know that it’s true.” My daughter, the psychology graduate school student who is well on her way to receiving a doctorate and has a special interest in anxiety and OCD, informs me that some of the situations I am referring to could technically meet the DSM-5 diagnostic criteria for OCD if they lead to sufficient impairment in functioning, if symptoms persist for more than one hour per day, and if they give rise to significant distress.

One’s body — like the brain — can generate “noise,” and it is fair to say that the human body in which complex multiple systems are functioning synchronously generates a substantial amount of such “noise.” A common feature of many of the patients that I am referring to is hyperawareness, with such hyperfocus often capable of magnifying “noise” into what is perceived as a “signal.” The reality is that “noise” is much less meaningful as compared to a true “signal,” and should not be attributed more significance and gravity because it is perceived as a physical sensation.

As an aside, one of the personal “noises” that I experience is floaters in my visual fields. These are spots or specks that appear like cobwebs and dart about when I move my eyes, particularly evident in bright light. If I make the conscious choice to focus on them, they become highly annoying, intrusive, and disturbing. So the best solution — as an ophthalmologist once stated to me — is to “sit back and enjoy them.” By not focusing on them, they fade into the background and essentially become invisible. The bottom line is that by allowing for the “noise” without directing attention to it, the potential power and authority of that noise will be diminished. The same refers to tinnitus, the ringing in the ears that many adults experience, myself included in that club.

THREE NOT UNCOMMON OCD UROGENITAL SCENARIOS

To Pee or Not to Pee, That is the Question: Ritual Voiding

I have many patients who have a ritual compulsion that they regard as necessary to get to sleep. Obsessed with completely emptying the bladder, they strive for a “just right” or “empty” feeling to ensure a good night’s sleep. Characteristically, they urinate immediately prior to sleep and then get into bed, but are unable to fall asleep, hyperfocused on any residual sensation of urinary urgency that they might have. They return to the bathroom on one or often more occasions over a brief period of time, despite the bladder being essentially empty, and perhaps are able to urinate a small additional volume each time. This behavior is repeated until the compulsion satisfies the perceived urgency and they are finally able to achieve sleep. This ritualistic behavior is done repeatedly and becomes reinforced and then ultimately is solidified as a maladaptive habit.

Frequency of voiding to achieve optimal emptying is not always just a sleeptime issue, as for many patients this scenario may occur at any time of the day. For some, it is triggered by a situation in which no bathroom will be readily available (e.g., a long car trip, a Broadway play, getting on an airplane, etc.). Hyperfocus on the bladder and the anticipatory anxiety regarding the situation they will need to confront is dealt with by numerous trips to the bathroom, causing inconvenient frequency of voiding. Those who have anxiety associated with limited access to bathrooms typically request aisle seats on airplanes.

How to manage this issue: According to my daughter — the burgeoning OCD specialist — the first step is to prioritize what OCD experts call “response prevention,” which is delaying or completely stopping the compulsion. This translates to delaying or resisting going to the bathroom after emptying once and sitting tight with the anxiety, discomfort, and uncertainty that may eventuate. However, if one’s symptoms are interfering with multiple aspects of their life or one notices OCD behaviors or tendencies in other domains as well, she recommends reaching out to an OCD specialist to have ERP (exposure and response prevention) and more psychological support. The best resources can be found on the IOCDF (International OCD Foundation) website.

With respect to urinary sensation — although quite variable — for most people the initial sense of urgency is perceived at 3-5 ounces of filling, a stronger sensation at 8-10 ounces of filling, and total bladder capacity at 12-15 ounces or so. After the bladder is emptied, it is typical to have a small amount of residual urine volume that remains in the bladder. Under normal circumstances, the “noise” that the bladder generates is ignored until it becomes a true “signal.” The sensation of urgency perceived may be a “noise” — a false perception that is OCD-engendered, or an actual “signal,” if the underlying basis is a bonafide urological issue (urinary infection, overactive bladder, underactive bladder, prostate obstruction, etc.). Regardless, the perceived urgency, whether real or not, demands relief by urinating, which results in frequent voiding of relatively small volumes.

At times, even after effective treatment of a physical cause of urgency (e.g., a urinary infection), hyperfocus on bladder sensations persists, with the patient reacting by compulsively voiding, resulting in a maladaptive urinary frequency. I have named this post-UTI issue P.I.S.S. (Post-Infection Sensitivity Syndrome). What is usually “back burner” has become “front burner,” and ultimately the maladaptive coping strategy leads to even more distress with the constant visits to the bathroom.

Stare at it Long Enough and It Will Become Real: Obsessive Genital Focus

I have witnessed many young adult male patients obsessed with minor penile “imperfections.” Penises are as unique and variable as snowflakes in terms of size, shape, color, and texture. Beyond “size matters”— often a source of male fixation (and a topic for another day) — a certain population of men are preoccupied, if not obsessed, with the appearance of their genitals. In my interactions with patients, concerns are often voiced about symmetry, color, pigmentation, angulation, spots, blemishes, veinous patterns, loose skin, and other oddities. Unless you are in the habit of closely inspecting other men’s genitals (as urologists are), you are unlikely to realize how common and completely normal most of these genital variations are.

Clearly, if one hyperfocuses on any area of the body for enough time, one can recognize minor “flaws” that are only normal anatomical variants, and the concern and anxiety generated are often sufficient to drive constant self-examination and scrutinization of the perceived flaw and ultimately a urological consultation. Most of the time, education and reassurance that this issue is not a serious problem is sufficient to break the cycle. I have composed a handout for patients entitled ‘10 Common Penile “Flaws” You May Have That Are Actually Quite Normal’ to reinforce the verbal information and reassurance relayed during the office consultation. Importantly, if this situation was true OCD, reassurance would be insufficient management, as it would result only in short-term relief. If after one visit to the urologist it becomes clear that the problem persists, referral to a mental health professional is in order.

Marital Straying-Induced Sensations: Cheating Guilt

Over the years, I have had numerous patients seen in consultation concerning perceived genital issues following some act of marital infidelity. For example, a young man goes to a strip club, consumes a good amount of alcohol, and is the recipient of oral sex. Thereafter, wracked with guilt about the straying aspect as well as anxiety about a possible sexually transmitted infection (STI), he hyperfocuses on his genitals and notices vague symptoms of pain, pressure, sensitivity, etc., that may be real or not and may involve the penis, testes, scrotum, groin, perineum, etc. The excessive focus and fixation become an acute obsession, and the compulsion is to inspect, probe, prod, and poke, actions that may further exacerbate the perceived problem. Although it is entirely possible that a genuine STI may be the driver of the symptoms, in most cases that is not the case. Education, reassurance and an STI screen to rule out an infection will usually eradicate the problem.

Bottom Line: Sensations originating from the urinary or genital tract may be genuine “signals”, or alternatively, “noise.” One may choose to accept and allow for the “noise” without directing attention to it, or, alternatively, hyperfocus on it. An obsessive focus may lead to compulsive thoughts and/or behaviors, including catastrophizing, urinating frequently, constant self-examination, physical probing, doing Google searches, etc., with the possibility that the obsession and reactive compulsion results in a maladaptive behavior that may require a psychological evaluation if the urologist is not capable of managing the problem. Note that psychologists when confronting a patient with uro-genital somatic OCD symptoms will request that the patient initially see a urologist to rule out an underlying medical issue.

I will close with a statement by Patricia Thornton, PhD: “If you can accept uncomfortable physical sensation, as well as intrusive unwelcome thoughts without doing anything to mitigate them, you are on your way to conquering OCD!”

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. His mission is to “bridge the gap” between the public and the medical community.

He is an Assistant Clinical Professor in the Department of Urology at Hackensack Meridian School of Medicine and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. He is a urologist at New Jersey Urology, a Summit Health Company. He is the co-founder of PelvicRx and Private Gym.

Dr. Siegel is the author of several books. The newly revised second edition (June 2023) of Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now available in print and Kindle formats on Amazon.