Cystocele, midline
ICD-10 N81.11 is a billable code used to indicate a diagnosis of cystocele, midline.
A cystocele, also known as a bladder prolapse, occurs when the bladder bulges into the front wall of the vagina due to weakened pelvic floor muscles and connective tissues. This condition is often associated with childbirth, aging, and hormonal changes, particularly in postmenopausal women. A midline cystocele specifically refers to the protrusion occurring centrally in the vaginal wall. Symptoms may include urinary incontinence, a feeling of pressure or fullness in the pelvic area, and discomfort during sexual intercourse. Diagnosis typically involves a pelvic examination, where the physician may observe the bulge during a cough or Valsalva maneuver. Treatment options vary from conservative management, such as pelvic floor exercises and pessaries, to surgical interventions aimed at repairing the pelvic support structures. Understanding the relationship between cystocele and other conditions such as endometriosis, female genital prolapse, and ovarian disorders is crucial for comprehensive patient care.
Detailed patient history, physical examination findings, and treatment plans must be documented.
Patients presenting with urinary incontinence or pelvic pressure.
Urologists should ensure that all associated conditions are documented to support the diagnosis.
Comprehensive pelvic examination findings and any imaging studies performed.
Women experiencing pelvic organ prolapse or related symptoms.
Gynecologists should document the relationship between cystocele and other gynecological disorders.
Used when a patient undergoes surgical intervention for cystocele repair.
Surgical notes must detail the procedure performed and any complications.
Urologists and gynecologists should ensure that the diagnosis supports the need for surgery.
A cystocele involves the bladder protruding into the vaginal wall, while a rectocele involves the rectum bulging into the vaginal wall. Accurate coding requires distinguishing between these two conditions.
