Learn about Benign Prostatic Hypertrophy with Urinary Retention, also known as BPH with Urinary Retention and Prostatic Hyperplasia with Retention. This resource provides information on diagnosis, clinical documentation, and medical coding for BPH with urinary retention, focusing on healthcare best practices and accurate terminology for medical professionals. Find details on ICD-10 codes, symptoms, and treatment options for Prostatic Hyperplasia with Retention to support proper clinical documentation and improve patient care.
Also known as
Diseases of male genital organs
Covers conditions affecting the male reproductive system, including the prostate.
Other symptoms and signs involving the urinary system
Includes urinary retention and other related symptoms not classified elsewhere.
Other disorders of the urinary system
Encompasses various urinary disorders, some of which may be related to BPH.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is urinary retention due to BPH?
Yes
Is there a confirmed diagnosis of BPH?
No
Is there another cause for the retention?
When to use each related code
| Description |
|---|
| Enlarged prostate with inability to urinate. |
| Enlarged prostate without blockage. |
| Sudden inability to urinate. |
Coding requires specifying acute or chronic urinary retention. Missing documentation can lead to inaccurate codes like N40.1 instead of N40.0.
Documentation lacking details (obstructive vs non-obstructive) can lead to coding errors and affect DRG assignment for reimbursement.
Incorrectly coding related conditions like UTI or hydronephrosis as separate diagnoses if they're integral to BPH with retention inflates severity.
Q: What are the best evidence-based practices for managing acute urinary retention in elderly patients with Benign Prostatic Hypertrophy?
A: Managing acute urinary retention (AUR) in elderly patients with Benign Prostatic Hypertrophy (BPH) requires a multi-faceted approach. Initial management involves prompt bladder decompression with urethral catheterization. For patients with significant post-void residual volume and bothersome lower urinary tract symptoms (LUTS), consider alpha-blockers (e.g., tamsulosin, alfuzosin) or 5-alpha reductase inhibitors (e.g., finasteride, dutasteride) for long-term BPH management. For refractory cases or those with large prostates (>40g), surgical interventions like transurethral resection of the prostate (TURP) or Holmium laser enucleation of the prostate (HoLEP) might be necessary. Explore how different surgical techniques compare in terms of efficacy and complications. Additionally, assess and address any underlying comorbidities that may exacerbate BPH/AUR, such as diabetes, heart failure, or neurological conditions. Learn more about the AUA guidelines for the management of BPH.
Q: How can I differentiate between BPH with Urinary Retention and other causes of urinary retention in male patients, such as prostate cancer or neurogenic bladder?
A: Differentiating Benign Prostatic Hypertrophy with Urinary Retention (BPH with UR) from other causes requires a thorough clinical evaluation. Start with a detailed history including symptom onset, duration, and associated factors. Perform a digital rectal examination (DRE) to assess prostate size, symmetry, and consistency. While BPH typically presents with a smooth, enlarged prostate, a hard or nodular prostate raises suspicion for prostate cancer. Serum prostate-specific antigen (PSA) testing should be considered, particularly for patients with an abnormal DRE or high-risk factors. Urodynamic studies can help distinguish BPH with UR from neurogenic bladder by evaluating bladder function and identifying potential neurological causes. Consider implementing a diagnostic algorithm incorporating these elements to ensure accurate diagnosis and guide appropriate management. Explore further the role of imaging, such as pelvic ultrasound or MRI, in complex cases.
Patient presents with complaints consistent with benign prostatic hyperplasia BPH with urinary retention. Symptoms include weak urinary stream, hesitancy, straining to void, incomplete emptying, nocturia, and a sensation of bladder fullness even after voiding. Digital rectal examination DRE revealed an enlarged, smooth, and non-tender prostate. Post-void residual PVR urine volume was significantly elevated, confirming urinary retention. The patient denies any fever, chills, or dysuria, suggesting the absence of acute prostatitis. Differential diagnoses considered include bladder outlet obstruction BOO, neurogenic bladder, and urethral stricture. Given the patient's presentation, age, and DRE findings, the diagnosis of benign prostatic hyperplasia with urinary retention is most likely. Treatment options including medication management with alpha-blockers or 5-alpha reductase inhibitors, and minimally invasive procedures such as transurethral resection of the prostate TURP or laser therapy, were discussed. Patient education on the importance of lifestyle modifications, such as limiting fluid intake before bedtime and avoiding caffeine and alcohol, was provided. Follow-up appointment scheduled to monitor treatment response and assess post-void residual urine volume. ICD-10 code N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms and CPT codes for appropriate evaluation and management services will be documented.