Urethrocele
ICD-10 N81.0 is a billable code used to indicate a diagnosis of urethrocele.
Urethrocele is a condition characterized by the protrusion of the urethra into the anterior wall of the vagina, often associated with pelvic floor disorders. It occurs when the supportive tissues of the pelvic floor weaken, leading to a bulging of the urethra. This condition is commonly seen in women, particularly those who have experienced childbirth, menopause, or other factors that contribute to pelvic floor weakening. Urethrocele can present with symptoms such as urinary incontinence, difficulty in urination, and a sensation of pressure or fullness in the vaginal area. It may coexist with other forms of pelvic organ prolapse, such as cystocele (bladder prolapse) and rectocele (rectal prolapse). Diagnosis typically involves a pelvic examination and may include imaging studies to assess the extent of the prolapse. Treatment options range from conservative management, including pelvic floor exercises and pessaries, to surgical interventions aimed at repairing the prolapse and restoring normal anatomy. Understanding the relationship between urethrocele and other conditions like endometriosis, female genital prolapse, and ovarian disorders is crucial for comprehensive patient management.
Detailed history of urinary symptoms, physical examination findings, and any imaging studies performed.
Patients presenting with urinary incontinence, pelvic pain, or vaginal bulging.
Ensure accurate documentation of the type and severity of prolapse, as well as any co-existing conditions.
Comprehensive pelvic examination findings, including assessment of pelvic organ support and any surgical history.
Women with pelvic organ prolapse, especially post-menopausal women or those with a history of childbirth.
Document any conservative management strategies attempted prior to surgical intervention.
Used when surgical intervention is performed for urethrocele.
Operative report detailing the procedure and findings.
Urology and gynecology should coordinate documentation to ensure accurate coding.
Common symptoms include urinary incontinence, a feeling of pressure or fullness in the vaginal area, and difficulty urinating. Some patients may also experience recurrent urinary tract infections.
