Cystocele, lateral

This code describes a prolapse of the urinary bladder into the vagina, specifically when the bladder herniates through the lateral vaginal wall. It indicates a defect in the paravaginal support structures, distinct from a midline or central cystocele.

Use this code when documentation clearly specifies a cystocele with a lateral component or a paravaginal defect. This diagnosis is typically made during a pelvic examination, often confirmed by imaging studies like dynamic MRI or ultrasound, showing the bladder bulging into the lateral vaginal fornix.

• Differentiate from N81.10 (Cystocele, unspecified) and N81.11 (Cystocele, midline) based on documentation of the specific anatomical defect.
• Code any associated pelvic organ prolapse conditions (e.g., rectocele, uterine prolapse) separately.
• Ensure the medical record specifies "lateral" or "paravaginal" to support the use of this specific code.