Urethral discharge without blood
ICD-10 R36.0 is a billable code used to indicate a diagnosis of urethral discharge without blood.
Urethral discharge without blood (R36.0) refers to the abnormal secretion from the urethra that is not accompanied by blood. This symptom can be indicative of various underlying conditions, including infections, inflammation, or other urogenital disorders. Common causes include sexually transmitted infections (STIs) such as gonorrhea and chlamydia, non-specific urethritis, and prostatitis. Patients may present with additional symptoms such as dysuria (painful urination), increased urinary frequency, or discomfort in the genital area. Laboratory findings may include the presence of leukocytes or bacteria in urine or urethral swabs, which can help in diagnosing the underlying cause. Accurate documentation of the characteristics of the discharge (e.g., color, consistency, odor) and associated symptoms is crucial for effective diagnosis and treatment planning.
Detailed patient history, including sexual history, and physical examination findings.
Patients presenting with urethral discharge during routine check-ups or after unprotected sexual encounters.
Consideration of co-existing conditions such as urinary tract infections or prostatitis.
Acute care notes, including vital signs and immediate assessment findings.
Patients presenting with acute urethral discharge and associated symptoms like fever or severe pain.
Rapid assessment and potential need for immediate treatment or referral.
Used when testing for STIs in patients presenting with urethral discharge.
Document the reason for testing and any associated symptoms.
Internal medicine and infectious disease specialists may frequently order these tests.
Document the characteristics of the discharge, any associated symptoms, and the results of any diagnostic tests performed.
