Cystocele, lateral
ICD-10 N81.12 is a billable code used to indicate a diagnosis of cystocele, lateral.
A lateral cystocele is a type of pelvic organ prolapse where the bladder bulges into the anterior wall of the vagina, specifically towards one side. This condition often arises due to weakened pelvic support structures, which can be exacerbated by factors such as childbirth, aging, obesity, and chronic cough. Patients may present with symptoms including urinary incontinence, a sensation of pressure or fullness in the pelvic area, and difficulty emptying the bladder completely. In some cases, a lateral cystocele may coexist with other pelvic floor disorders, such as rectocele or uterine prolapse. The diagnosis is typically made through a physical examination, where the clinician may observe the bulge during a cough or Valsalva maneuver. Treatment options vary from conservative management, such as pelvic floor exercises and pessary use, to surgical interventions aimed at restoring normal anatomy and function. Understanding the interplay between cystocele and other conditions like endometriosis, ovarian disorders, and female genital tract polyps is crucial, as these may influence treatment decisions and outcomes.
Detailed patient history, physical examination findings, and any imaging studies.
Patients presenting with urinary incontinence or pelvic pressure.
Consideration of bladder function tests and potential surgical interventions.
Comprehensive pelvic examination findings and assessment of associated gynecological conditions.
Women with pelvic organ prolapse and associated symptoms.
Documentation of any concurrent gynecological issues such as endometriosis or fibroids.
Used when surgical intervention is performed for cystocele repair.
Operative report detailing the procedure and findings.
Urology or gynecology specialists should document the surgical approach and any complications.
A lateral cystocele specifically refers to the bulging of the bladder into the vaginal wall on one side, whereas other types may involve the anterior wall without lateral specificity.
