Retention of urine, unspecified
ICD-10 R33.9 is a billable code used to indicate a diagnosis of retention of urine, unspecified.
Retention of urine, unspecified (R33.9) refers to the inability to completely empty the bladder, leading to the accumulation of urine. This condition can manifest as acute or chronic urinary retention, with symptoms including a weak urine stream, straining to urinate, and a sensation of incomplete bladder emptying. Patients may present with abdominal discomfort, distension, or even acute urinary retention, which can lead to severe complications such as bladder damage or urinary tract infections. The underlying causes can vary widely, including obstruction (e.g., benign prostatic hyperplasia, urethral strictures), neurological disorders (e.g., spinal cord injuries, multiple sclerosis), or medication side effects. Diagnosis typically involves a thorough clinical history, physical examination, and may include bladder ultrasound or urodynamic studies to assess bladder function and urine flow. Laboratory tests may also be performed to rule out infections or other underlying conditions. Accurate coding requires careful documentation of the patient's symptoms, clinical findings, and any diagnostic tests performed.
Detailed patient history, physical examination findings, and results of any diagnostic tests performed.
Patients presenting with chronic urinary retention due to benign prostatic hyperplasia or neurological conditions.
Consideration of comorbidities that may affect urinary function, such as diabetes or neurological disorders.
Acute care documentation including vital signs, immediate interventions, and any imaging or laboratory results.
Patients presenting with acute urinary retention requiring catheterization or other urgent interventions.
Rapid assessment and intervention are critical; documentation should reflect the urgency of the situation.
Used in cases of acute urinary retention for bladder decompression.
Document the indication for catheterization and any complications.
Emergency medicine providers should document the urgency and rationale for the procedure.
Document the patient's symptoms, clinical findings, any diagnostic tests performed, and the clinical rationale for the diagnosis of unspecified urinary retention.
