Perineocele
ICD-10 N81.81 is a billable code used to indicate a diagnosis of perineocele.
Perineocele refers to a condition characterized by the protrusion of the rectum into the perineal area, often resulting from weakening of the pelvic floor muscles and connective tissues. This condition can occur in women who have experienced childbirth, particularly those with multiple deliveries or significant perineal trauma. Perineocele is often associated with other pelvic floor disorders, including pelvic organ prolapse, where the pelvic organs descend into the vaginal canal. It may also be linked to endometriosis, which can cause pelvic pain and contribute to structural changes in the pelvic region. The presence of fistulas, ovarian disorders, and polyps of the female genital tract can complicate the clinical picture, as these conditions may coexist with perineocele and require careful evaluation and management. Diagnosis typically involves a thorough pelvic examination, imaging studies, and sometimes endoscopic procedures to assess the extent of the condition and any associated abnormalities. Treatment options may include pelvic floor rehabilitation, surgical intervention, or a combination of both, depending on the severity of the symptoms and the presence of other pelvic disorders.
Detailed history of childbirth, pelvic examinations, and any imaging studies performed.
Patients presenting with pelvic pain, urinary incontinence, or vaginal bulging.
Documentation should clearly outline the relationship between perineocele and any other pelvic disorders.
Assessment of urinary symptoms and any urodynamic studies performed.
Patients with urinary retention or incontinence related to pelvic floor dysfunction.
Urologists should document any surgical interventions related to pelvic floor repair.
Used when surgical intervention is performed for perineocele.
Operative report detailing the procedure and findings.
Obstetricians and gynecologists should ensure clear documentation of indications for surgery.
The primary cause of perineocele is the weakening of pelvic floor muscles and connective tissues, often due to childbirth, aging, and hormonal changes.
Perineocele is diagnosed through a pelvic examination, imaging studies, and sometimes endoscopic procedures to assess the extent of the condition.
