Chlamydial infection of lower genitourinary tract, unspecified
ICD-10 A56.3 is a billable code used to indicate a diagnosis of chlamydial infection of lower genitourinary tract, unspecified.
Chlamydial infection of the lower genitourinary tract is a common sexually transmitted infection (STI) caused by the bacterium Chlamydia trachomatis. This infection primarily affects the urethra in men and the cervix in women, but it can also involve the rectum and throat. Many individuals with chlamydial infections are asymptomatic, which can lead to delayed diagnosis and treatment. Symptoms, when present, may include dysuria, increased urinary frequency, abnormal vaginal discharge, and pelvic pain in women. In men, symptoms may include urethral discharge and testicular pain. The infection can lead to serious complications if left untreated, such as pelvic inflammatory disease (PID) in women and epididymitis in men. Screening and early detection are crucial, especially in high-risk populations, to prevent long-term health issues. Treatment typically involves antibiotics, with azithromycin or doxycycline being the most commonly prescribed. Contact tracing is essential to prevent reinfection and further transmission, as partners of infected individuals should also be tested and treated if necessary.
Detailed patient history, including sexual history and risk factors, and documentation of treatment plans.
Diagnosis of chlamydia in symptomatic and asymptomatic patients, management of complications.
Consideration of co-infections with other STIs and the need for partner treatment.
Documentation of pelvic exams, lab results, and treatment plans.
Routine screening in sexually active women, management of PID.
Importance of documenting patient education regarding STI prevention.
Used for laboratory confirmation of chlamydial infection.
Document the reason for testing and patient consent.
Infectious disease specialists should ensure comprehensive STI screening.
Common symptoms include dysuria, abnormal discharge, and pelvic pain in women. Many individuals may be asymptomatic.
Chlamydial infections are typically treated with antibiotics such as azithromycin or doxycycline.
Contact tracing helps prevent the spread of infection by ensuring that sexual partners are tested and treated.
