Cystocele
ICD-10 N81.1 is a billable code used to indicate a diagnosis of cystocele.
Cystocele, also known as a bladder prolapse, occurs when the bladder bulges into the anterior wall of the vagina due to weakened pelvic support structures. This condition is often associated with childbirth, aging, and hormonal changes, particularly in postmenopausal women. Symptoms may include urinary incontinence, a feeling of pressure or fullness in the pelvic area, and difficulty emptying the bladder completely. Cystocele can be classified based on severity, ranging from mild to severe, with more severe cases requiring surgical intervention. The condition can coexist with other pelvic floor disorders, such as rectocele and uterine prolapse, and may be exacerbated by conditions like endometriosis, which can lead to pelvic adhesions and further compromise pelvic support. Accurate diagnosis typically involves a pelvic examination and may include imaging studies to assess the extent of the prolapse. Treatment options vary from conservative management, such as pelvic floor exercises and pessaries, to surgical repair, depending on the severity of symptoms and the patient's overall health status.
Detailed history of urinary symptoms, physical examination findings, and treatment plans.
Patients presenting with urinary incontinence, pelvic pressure, or recurrent urinary tract infections.
Consideration of surgical history and other pelvic floor disorders is crucial for accurate coding.
Comprehensive pelvic examination findings, including the degree of prolapse and associated symptoms.
Women with pelvic organ prolapse seeking surgical intervention or conservative management.
Documentation should include any co-existing conditions such as endometriosis or uterine fibroids.
Performed for surgical repair of cystocele.
Operative report detailing the procedure and indications.
Urology and gynecology may both perform this procedure.
Common symptoms include urinary incontinence, pelvic pressure, and difficulty emptying the bladder. Some women may also experience recurrent urinary tract infections.
Cystocele is diagnosed through a pelvic examination, where the physician assesses the degree of prolapse. Imaging studies may also be used to evaluate the condition.
