K44.9 - Diaphragmatic hernia without obstruction or gangrene

Clinical Definition

Vaginal cystocele is a hernial protrusion of the bladder into the vagina due to weakening of the anterior vaginal wall supporting tissues. This results in the bladder pushing against and moving the vaginal wall, creating a bulge.

Documentation Requirements

• Anatomical specificity:

  • Confirm "anterior" wall involvement

  • Document presence of vaginal wall prolapse

  • Specify severity/grade (1-4)

• Status:

  • Initial diagnosis vs. recurrent

  • Presence/absence of symptoms

• Associated conditions:

  • Document any urinary symptoms

  • Note presence/absence of other pelvic organ prolapse

• Supporting findings:

  • Physical exam findings

  • Any imaging results if performed

Common Synonyms

• Dropped bladder

• Bladder prolapse

• Anterior wall prolapse

• Fallen bladder

• Pelvic organ prolapse (when referring to bladder specifically)

Coding Conflicts

Excludes1:

• Cystocele with uterine prolapse

• Complete uterovaginal prolapse

Excludes2:

• Cystourethrocele

• Other urethral conditions

Scribing.io Automation

Scribing.io's AI recognizes key phrases like "anterior vaginal wall bulge," "bladder prolapse," and "cystocele" during patient encounters. The system automatically:

• Tags anatomical descriptors

• Captures severity grades when mentioned

• Links associated urinary symptoms

• Flags when documentation is insufficient for proper coding

• Prompts for missing elements like grade or specific wall involvement