Learn about bladder retention (urinary retention), the inability to completely empty the bladder. This guide covers diagnosis, causes, treatment, ICD-10 codes for bladder retention, and clinical documentation tips for healthcare professionals. Find information on managing urinary retention and improving patient care.
Also known as
Other urinary retention
Covers other specified types of urinary retention not classified elsewhere.
Postoperative urinary retention
Urinary retention specifically occurring after a surgical procedure.
Other specified urinary incontinence
While not retention, includes overflow incontinence, sometimes caused by retention.
Other postoperative genitourinary complications
May be relevant if retention is a complication following genitourinary surgery.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the bladder retention due to an obstruction?
Yes
Is obstruction due to a neurogenic cause?
No
Is retention due to medication?
When to use each related code
| Description |
|---|
| Inability to completely empty the bladder. |
| Incomplete bladder emptying, some urine remains. |
| Sudden, painful inability to urinate requiring urgent care. |
Coding bladder retention without specifying acute or chronic status can lead to inaccurate reimbursement and quality reporting.
Failing to capture underlying causes like BPH or neurological conditions impacts severity scores and case mix index.
Miscoding postoperative urinary retention as a pre-existing condition can lead to denials and compliance issues.
Q: What are the key differential diagnoses to consider when a patient presents with acute urinary retention, and how can I differentiate between them?
A: Acute urinary retention (AUR) requires a prompt and accurate diagnosis to ensure appropriate management. Several key differential diagnoses must be considered, including bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH) or prostate cancer, neurological conditions such as spinal cord injury or multiple sclerosis, medication side effects (e.g., anticholinergics, antidepressants), fecal impaction, and psychogenic urinary retention. Differentiating between these requires a thorough history, including medication review and assessment of neurological symptoms. A physical exam, including a digital rectal exam (DRE) to assess prostate size and consistency, is crucial. Further investigations like urinalysis, post-void residual (PVR) measurement via bladder scan or catheterization, and potentially urodynamic studies or imaging (e.g., ultrasound, CT) can help pinpoint the underlying cause. Explore how incorporating a standardized diagnostic approach can improve AUR management in your practice.
Q: What are the best evidence-based practices for managing chronic urinary retention in older adults with comorbidities, specifically focusing on minimizing catheter-associated urinary tract infections (CAUTIs)?
A: Managing chronic urinary retention in older adults with comorbidities often necessitates long-term catheterization, increasing the risk of catheter-associated urinary tract infections (CAUTIs). Evidence-based practices to minimize CAUTIs include using the smallest bore catheter possible, intermittent catheterization when feasible, strict adherence to aseptic technique during catheter insertion and maintenance, and regular catheter changes based on individual patient needs and clinical guidelines. Consider implementing bladder training programs and exploring alternative drainage methods, such as suprapubic catheters, which may reduce CAUTI risk compared to indwelling urethral catheters. Furthermore, optimizing management of underlying comorbidities, such as diabetes, can contribute to better bladder health. Learn more about the latest guidelines for CAUTI prevention in geriatric patients with chronic urinary retention.
Patient presents with complaints consistent with bladder retention, also known as urinary retention or inability to urinate. Symptoms include lower abdominal discomfort, a sensation of incomplete bladder emptying, weak or intermittent urinary stream, and urgency with reduced voiding volume. Physical examination revealed a palpable, distended bladder. The patient reports increasing difficulty initiating urination and a feeling of fullness even after voiding. Differential diagnosis includes benign prostatic hyperplasia, urethral stricture, neurogenic bladder, and medication side effects. Assessment points to acute urinary retention based on patient history, physical findings, and symptom onset. Plan includes immediate bladder catheterization for urinary drainage and relief of discomfort. Post-void residual measurement will be obtained. Further investigation into the underlying cause of urinary retention will be conducted, including urinalysis and potentially urodynamic studies, cystoscopy, or imaging studies like ultrasound or CT scan of the abdomen and pelvis. Patient education provided regarding the importance of follow-up care and potential complications of untreated bladder retention, such as urinary tract infections and kidney damage. ICD-10 code R33.8 will be used for this encounter, and CPT codes will be determined based on the procedures performed. Treatment goals focus on restoring normal bladder function, preventing recurrence, and addressing any underlying medical conditions contributing to the urinary retention.