ICD-10 Code for Bladder Prolapse (Cystocele)
The ICD-10 code for a prolapsed bladder (cystocele) in females is N81.1.
Code Specifications
N81.1 specifically designates cystocele, which is the herniation of the bladder through the anterior vaginal wall 1, 2.
This code applies regardless of the severity or stage of the prolapse 2.
The code is used for both symptomatic and asymptomatic presentations of bladder prolapse 1.
Related ICD-10 Codes to Consider
When documenting cystocele, you may need to consider these additional codes depending on the clinical presentation:
N81.10: Cystocele, unspecified (when the specific type is not documented) 1.
N81.11: Cystocele, midline (when the prolapse is centrally located) 1.
N81.12: Cystocele, lateral (when there is paravaginal defect involvement) 1.
N39.3: Should be added if stress urinary incontinence is present concurrently 1.
N81.2: For incomplete uterovaginal prolapse if the apical compartment is also involved 3.
N81.6: For rectocele if posterior compartment prolapse coexists 3.
Clinical Documentation Tips
Always document the POP-Q stage in your clinical notes, as this affects treatment planning even though it doesn't change the primary ICD-10 code 3, 4.
Specify whether urinary symptoms (incontinence, retention, voiding dysfunction) are present, as these require additional codes 1.
Note if the cystocele is associated with levator ani muscle avulsion, as this predicts recurrence risk and may influence surgical planning 5, 6.
Document any concurrent prolapse in other compartments (apical or posterior), as multi-compartment involvement requires additional codes and affects management 3.