Cystocele, unspecified
ICD-10 N81.10 is a billable code used to indicate a diagnosis of cystocele, unspecified.
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, frequent urination, and a sensation of pressure or fullness in the pelvic area. In some cases, cystocele can coexist with other pelvic floor disorders such as rectocele or uterine prolapse. Diagnosis typically involves a pelvic examination, and treatment options range from pelvic floor exercises and lifestyle modifications to surgical interventions, depending on the severity of the condition. The unspecified nature of this code indicates that the specific characteristics of the cystocele, such as its size or associated symptoms, are not detailed, which can complicate treatment planning and coding accuracy.
Detailed history of urinary symptoms, physical examination findings, and any imaging studies performed.
Patients presenting with urinary incontinence, pelvic pressure, or recurrent urinary tract infections.
Ensure documentation reflects the relationship between cystocele and urinary symptoms for accurate coding.
Comprehensive pelvic examination findings, including any associated pelvic organ prolapse.
Women presenting with pelvic pain, urinary issues, or during routine gynecological exams.
Document any surgical interventions or conservative management strategies employed.
Used when surgical intervention is performed for cystocele repair.
Operative report detailing the procedure and indication for surgery.
Urology and gynecology should coordinate documentation to ensure accurate coding.
Cystocele specifically refers to the protrusion of the bladder into the vaginal wall, while other types of prolapse, such as rectocele or uterine prolapse, involve different pelvic organs.
