Congenital hydrocele
ICD-10 P83.5 is a billable code used to indicate a diagnosis of congenital hydrocele.
Congenital hydrocele is a condition characterized by the accumulation of serous fluid in the tunica vaginalis, the pouch of serous membrane surrounding the testis. This condition is typically observed in newborn males and can be unilateral or bilateral. The etiology of congenital hydrocele is often linked to the failure of the processus vaginalis to close after descent of the testes, leading to fluid accumulation. While congenital hydroceles are usually asymptomatic and may resolve spontaneously within the first year of life, they can occasionally lead to complications such as infection or hernia. Diagnosis is primarily clinical, based on physical examination findings, where a transilluminating mass may be noted in the scrotum. Treatment is generally conservative, but surgical intervention may be required if the hydrocele persists beyond the first year or if complications arise. Accurate coding of congenital hydrocele is essential for proper management and follow-up in neonatal care.
Detailed physical examination findings, including size and location of the hydrocele, and any associated symptoms.
Observation of a newborn male with a scrotal mass during routine examination in the NICU.
Documentation should include the timing of diagnosis and any interventions planned or performed.
Comprehensive history and physical examination, including family history of similar conditions.
Follow-up visits for a child with a previously diagnosed congenital hydrocele.
Consideration of developmental milestones and any impact of the condition on the child's growth.
Surgical intervention for persistent congenital hydrocele.
Operative report detailing the procedure and findings.
Neonatologists should ensure that the indication for surgery is well documented.
Most congenital hydroceles are monitored and may resolve spontaneously within the first year. Surgical intervention is considered if the hydrocele persists or complications arise.
