Phimosis
ICD-10 N47.1 is a billable code used to indicate a diagnosis of phimosis.
Phimosis is a condition characterized by the inability to retract the foreskin (prepuce) over the glans penis. This condition can be physiological in infants and young children, often resolving spontaneously as they grow. However, in older children and adults, phimosis can lead to complications such as pain during erections, difficulty with hygiene, and increased risk of infections. It may also contribute to conditions like balanitis (inflammation of the glans) and can complicate sexual function. In severe cases, phimosis may necessitate surgical intervention, such as circumcision or preputioplasty, to alleviate symptoms and prevent further complications. The condition can be associated with other penile disorders, including paraphimosis, where the retracted foreskin cannot be returned to its normal position, and may also impact male fertility indirectly by affecting sexual function. Proper diagnosis typically involves a physical examination and patient history, and treatment options should be discussed with a healthcare provider to determine the best course of action based on the severity of the condition.
Detailed patient history, physical examination findings, and treatment plan including any surgical interventions.
Adult patients presenting with painful erections or difficulty with hygiene; pediatric cases where parents express concerns about retractability.
Documentation should clearly outline the rationale for surgical intervention if performed, including any pre-existing conditions.
Observation of natural progression in infants, parental concerns, and any referrals to urology if complications arise.
Infants with physiological phimosis and parents seeking reassurance; older children with recurrent infections.
Documentation should differentiate between normal developmental phimosis and pathological cases requiring intervention.
Used when surgical intervention is required for phimosis.
Pre-operative assessment, consent forms, and post-operative care notes.
Urologists should document the indication for surgery clearly.
Physiological phimosis is a normal condition in infants and young children that typically resolves on its own, while pathological phimosis occurs due to scarring or other medical conditions and may require treatment.
