Dyspareunia
ICD-10 N94.1 is a billable code used to indicate a diagnosis of dyspareunia.
Dyspareunia refers to persistent or recurrent pain during sexual intercourse. This condition can significantly impact a woman's quality of life, emotional well-being, and intimate relationships. Dyspareunia can arise from various causes, including physical, psychological, and hormonal factors. Physical causes may include vaginal dryness, infections, pelvic inflammatory disease, endometriosis, or structural abnormalities. Psychological factors can encompass anxiety, depression, or a history of sexual trauma. Hormonal changes, particularly during menopause, can lead to vaginal atrophy, contributing to discomfort during intercourse. Accurate diagnosis often requires a thorough medical history, physical examination, and sometimes additional diagnostic tests. Treatment options vary based on the underlying cause and may include counseling, topical estrogen therapy, lubricants, or other medical interventions. Understanding the multifaceted nature of dyspareunia is crucial for effective management and improving patient outcomes.
Detailed patient history, physical examination findings, and treatment plans must be documented.
Patients presenting with pain during intercourse, vaginal dryness, or pelvic pain.
Consideration of hormonal status, especially in menopausal patients, and psychological evaluations.
Thorough assessment of psychological factors, including mental health history and current emotional state.
Patients with a history of trauma or anxiety affecting sexual function.
Coordination with gynecological assessments to address both physical and psychological aspects.
Used when evaluating a patient with dyspareunia during a routine gynecological visit.
Document the reason for the visit, history, examination findings, and treatment plan.
Obstetricians and gynecologists should ensure comprehensive documentation to support the diagnosis.
Dyspareunia can be caused by a variety of factors, including physical conditions like infections or endometriosis, hormonal changes, and psychological issues. A thorough evaluation is necessary to determine the specific cause.
