Superficial (introital) dyspareunia
ICD-10 N94.11 is a billable code used to indicate a diagnosis of superficial (introital) dyspareunia.
Superficial (introital) dyspareunia refers to pain experienced during sexual intercourse that occurs at the vaginal opening (introitus). This condition can be caused by various factors, including hormonal changes, infections, psychological issues, or anatomical abnormalities. In women, it is often associated with conditions such as vulvodynia, vaginismus, or atrophic vaginitis, particularly in the context of menopause when estrogen levels decline, leading to vaginal dryness and thinning of the vaginal walls. Additionally, superficial dyspareunia can be exacerbated by menstrual disorders, such as endometriosis, which may cause pelvic pain, or by complications arising from artificial fertilization procedures. Accurate diagnosis is crucial, as the underlying causes can significantly impact a woman's reproductive health and overall quality of life. Treatment options may include topical estrogen therapy, lubricants, pelvic floor physical therapy, or counseling for psychological factors. Understanding the multifactorial nature of this condition is essential for effective management and coding.
Detailed patient history, including sexual history, menstrual cycle details, and any previous treatments.
Patients presenting with pain during intercourse, recurrent vaginal infections, or post-menopausal symptoms.
Consideration of psychological factors and the impact of other gynecological conditions on dyspareunia.
Thorough evaluation of hormonal levels, fertility assessments, and any interventions related to artificial fertilization.
Patients undergoing fertility treatments who report pain during intercourse.
Understanding the implications of hormonal treatments on vaginal health and dyspareunia.
Used when a patient presents for evaluation of dyspareunia.
Document the patient's history, examination findings, and treatment plan.
Gynecologists should ensure comprehensive documentation to support the visit level.
Common causes include hormonal changes (especially during menopause), infections, vulvodynia, and psychological factors such as anxiety or past trauma.
