In simple words: After a hysterectomy, the top part of the vagina can sometimes lose its shape and bulge downwards. This is called a vaginal vault prolapse.

Prolapse of vaginal vault after hysterectomy. This condition occurs when the top part of the vagina loses its normal shape and drops down into the vaginal canal after a hysterectomy (surgical removal of the uterus).

Example 1: A 60-year-old female presents with pelvic pressure and a bulge in her vagina several months after undergoing a hysterectomy. Upon examination, she is diagnosed with a prolapse of the vaginal vault., A patient experiences difficulty with urination and bowel movements years after a hysterectomy, which is determined to be due to a vaginal vault prolapse., During a routine pelvic exam, a physician discovers a vaginal vault prolapse in an asymptomatic patient who had a hysterectomy in the past.

Documentation should include a detailed physical exam describing the degree of prolapse, any associated symptoms (pelvic pressure, urinary or bowel dysfunction, sexual discomfort), and relevant imaging studies (e.g., pelvic ultrasound) if performed.

** This code should only be used when the prolapse occurs after a hysterectomy. It does not apply to vaginal prolapse occurring for other reasons or for vaginal vault prolapse in patients who have not had a hysterectomy.As of December 1st, 2024, this information is current, but medical coding is subject to change, so it's essential to stay updated with the latest guidelines.