Rectocele
ICD-10 N81.6 is a billable code used to indicate a diagnosis of rectocele.
Rectocele is a condition characterized by the protrusion of the rectum into the posterior wall of the vagina, often resulting from weakened pelvic support structures. This condition is commonly associated with childbirth, aging, and increased intra-abdominal pressure. Women with rectocele may experience symptoms such as a sensation of fullness or pressure in the pelvic area, difficulty with bowel movements, and discomfort during sexual intercourse. The condition can also be linked to other pelvic floor disorders, including pelvic organ prolapse, which encompasses conditions like cystocele and uterine prolapse. Rectocele can coexist with endometriosis, where endometrial tissue grows outside the uterus, potentially complicating the clinical picture. Diagnosis typically involves a pelvic examination and may require imaging studies to assess the extent of the prolapse. Treatment options range from conservative management, such as pelvic floor exercises and lifestyle modifications, to surgical interventions aimed at repairing the prolapse. Accurate coding for rectocele is essential for proper reimbursement and to reflect the complexity of the patient's condition.
Detailed pelvic examination findings, patient history, and treatment plans.
Patients presenting with pelvic pressure, bowel dysfunction, or sexual discomfort.
Consideration of childbirth history and other pelvic floor disorders.
Comprehensive assessment of rectal function and associated bowel symptoms.
Patients with rectal prolapse or significant bowel dysfunction.
Assessment of surgical history and potential need for multidisciplinary management.
Used when surgical intervention is performed for rectocele.
Operative report detailing the procedure and indication.
Obstetrics and Gynecology or Colorectal Surgery may perform this procedure.
Common symptoms include pelvic pressure, difficulty with bowel movements, and discomfort during sexual intercourse.
Diagnosis is typically made through a pelvic examination, and imaging studies may be used to assess the extent of the prolapse.
Treatment options range from conservative management, such as pelvic floor exercises, to surgical repair depending on the severity of the condition.
