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2025 ICD-10-CM code N41.3

Prostatocystitis is inflammation of both the prostate gland and the bladder.

Always code the underlying cause of the prostatocystitis (if known), in addition to code N41.3.Refer to the official ICD-10-CM coding guidelines for further information on coding infections.

Modifiers may be applicable depending on the circumstances of the encounter and the services provided. Consult the official guidelines for modifier use.

Medical necessity for diagnosing and treating prostatocystitis is established when symptoms are consistent with the diagnosis and laboratory findings confirm the presence of infection. The treatment is medically necessary to prevent complications like sepsis or urosepsis. The chronic form may require longer-term management.

Diagnosis and treatment of prostatocystitis falls under the purview of urologists.The clinical responsibility involves taking a detailed patient history, performing a physical exam (including a digital rectal exam), and ordering laboratory tests (e.g., urinalysis, urine culture, PSA levels) to confirm the diagnosis and identify the causative agent. Treatment typically involves antibiotics tailored to the identified pathogen and management of symptoms.

IMPORTANT:Use additional code (B95-B97) to identify the infectious agent.

In simple words: Prostatocystitis means that both your prostate (a gland in men) and your bladder are inflamed, often due to an infection.This can cause pain when you urinate, needing to urinate more often, and other uncomfortable symptoms.

Prostatocystitis is a medical condition characterized by inflammation of the prostate gland and the urinary bladder.It is typically caused by bacterial infection, leading to symptoms such as pain during urination, frequent urination, back or pelvic pain, and general malaise. The prostate gland, located below the bladder and surrounding the urethra, contributes to seminal fluid production. The bladder stores urine produced by the kidneys before elimination through the urethra.

Example 1: A 60-year-old male patient presents with dysuria, urinary frequency, urgency, and lower back pain.Physical examination reveals tenderness to palpation of the prostate. Urinalysis shows pyuria and bacteriuria.Urine culture identifies E. coli.The diagnosis of prostatocystitis is made, and treatment with appropriate antibiotics is initiated., A 72-year-old male with a history of benign prostatic hyperplasia (BPH) experiences worsening urinary symptoms, including nocturia and incomplete bladder emptying, along with fever and chills.A diagnosis of acute bacterial prostatocystitis is made based on clinical findings and laboratory results.The patient requires intravenous antibiotics and supportive care., A 45-year-old male presents with chronic pelvic pain, urinary frequency, and intermittent dysuria.Physical examination shows a mildly enlarged, tender prostate.Laboratory findings are inconclusive. The patient undergoes a transrectal ultrasound and prostate biopsy to rule out other conditions, resulting in a final diagnosis of chronic prostatocystitis.

Complete history and physical exam, including digital rectal exam; urinalysis; urine culture and sensitivity; prostate-specific antigen (PSA) level; imaging studies (e.g., transrectal ultrasound) may be necessary to rule out other conditions.Documentation of treatment plan and response to therapy.

** The severity of prostatocystitis can range from mild to severe.Severe cases may require hospitalization.

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