Urethral discharge
ICD-10 R36 is a billable code used to indicate a diagnosis of urethral discharge.
Urethral discharge refers to the abnormal secretion from the urethra, which can manifest as a clear, cloudy, or purulent fluid. This symptom is often associated with infections, particularly sexually transmitted infections (STIs) such as gonorrhea and chlamydia, but can also result from non-infectious causes like urethritis due to irritants or trauma. The discharge may vary in color, consistency, and odor, providing clues to the underlying etiology. Clinical evaluation typically includes a thorough history and physical examination, focusing on associated symptoms such as dysuria, frequency, and urgency of urination. Laboratory tests, including urinalysis and cultures, are essential for identifying pathogens and guiding treatment. Accurate diagnosis is crucial, as urethral discharge can indicate serious conditions requiring prompt intervention.
Detailed history of symptoms, including onset, duration, and associated factors; results of urinalysis and cultures.
Patients presenting with dysuria and urethral discharge, often requiring STI screening.
Consideration of patient history, including sexual activity and previous infections, is crucial for accurate coding.
Acute presentation documentation, including vital signs and immediate lab results.
Patients with acute urethral discharge presenting with severe dysuria or systemic symptoms.
Rapid assessment and treatment initiation are critical; documentation must reflect urgency and rationale for interventions.
Used when a culture is performed to identify the causative organism of the discharge.
Document the reason for the culture and any relevant clinical findings.
In infectious disease specialties, ensure that the culture results are linked to the diagnosis.
Documentation should include the nature of the discharge, associated symptoms, results of any laboratory tests, and the clinical context of the visit.
