Urethral fistula
ICD-10 N36.0 is a billable code used to indicate a diagnosis of urethral fistula.
Urethral fistula is an abnormal connection between the urethra and another structure, which can lead to significant urinary complications. This condition may arise due to various factors, including trauma, surgical complications, or inflammatory diseases. Patients with urethral fistulas often present with symptoms such as continuous urinary leakage, recurrent urinary tract infections, and discomfort during urination. The diagnosis typically involves a thorough clinical evaluation, including a detailed patient history, physical examination, and imaging studies such as ultrasound or cystoscopy to visualize the fistula. Treatment options vary based on the fistula's size, location, and underlying cause, ranging from conservative management to surgical repair. Urethral fistulas can be associated with other urethral disorders, such as urethritis and urethral strictures, which may complicate the clinical picture and require careful coding to ensure accurate representation of the patient's condition.
Detailed operative reports and imaging studies to confirm the diagnosis and treatment plan.
Management of post-surgical urethral fistulas, evaluation of traumatic urethral injuries.
Urologists must document the size, location, and cause of the fistula for accurate coding.
Comprehensive assessment of urinary symptoms and any acute complications.
Patients presenting with acute urinary retention or infection secondary to a fistula.
Emergency physicians should document the patient's history and any immediate interventions performed.
Used when surgical intervention is performed to repair the fistula.
Operative report detailing the procedure and any complications.
Urologists should ensure that the procedure is well-documented to support the coding.
Common causes include surgical complications, trauma, and inflammatory conditions such as chronic urethritis.
Diagnosis typically involves a combination of patient history, physical examination, and imaging studies such as cystoscopy or ultrasound.
