Straining to void
ICD-10 R39.16 is a billable code used to indicate a diagnosis of straining to void.
Straining to void refers to the difficulty experienced by a patient when attempting to urinate, often characterized by excessive effort or discomfort. This symptom can arise from various underlying conditions affecting the urinary tract, bladder, or prostate. Common causes include urinary tract obstruction, benign prostatic hyperplasia (BPH), urinary tract infections (UTIs), and neurological disorders that impair bladder function. Patients may describe a sensation of incomplete bladder emptying, urgency, or pain during urination. Clinical evaluation typically involves a thorough history and physical examination, urinalysis, and possibly imaging studies to identify any anatomical abnormalities. Straining to void can significantly impact a patient's quality of life and may lead to complications such as urinary retention or recurrent infections if not addressed appropriately.
Detailed patient history, including duration and severity of symptoms, and any associated conditions.
Patients presenting with chronic urinary symptoms, particularly in older adults.
Consideration of comorbidities such as diabetes or neurological disorders that may affect bladder function.
Acute assessment of urinary symptoms, including vital signs and any immediate interventions.
Patients presenting with acute urinary retention or severe discomfort.
Rapid evaluation of potential obstructive causes, such as kidney stones or acute prostatitis.
Used when acute urinary retention is present.
Document the need for catheterization and the patient's symptoms.
Emergency medicine providers should document the urgency of the situation.
Straining to void can be caused by various factors, including urinary tract obstruction, benign prostatic hyperplasia, and neurological disorders affecting bladder function.
