Name of the Condition

• Unspecified injury of urethra, subsequent encounter
• Also known as urethral injury or trauma to the urethra.

Summary

• This condition involves damage to the urethra, which is the tube that carries urine from the bladder out of the body. The term "subsequent encounter" indicates ongoing or follow-up care after the initial treatment or diagnosis.

Causes

• Urethral injuries typically occur due to external trauma, such as accidents, falls, or impacts in sports. Medical procedures involving catheterization or surgery in the pelvic area could also lead to urethral injury.

Risk Factors

• Engaging in high-impact sports, having a history of pelvic surgeries, or being involved in traumatic accidents can increase the risk of urethral injury.

Symptoms

• Symptoms include blood in the urine, difficulty urinating, pain during urination, and possible swelling in the lower abdomen or pelvic area.

Diagnosis

• Diagnostic methods include physical examination, urinalysis, imaging tests like ultrasounds or cystourethrography, and endoscopy to visually inspect the urethra.

Treatment Options

• Treatment may involve catheterization to allow urine to flow without irritation of the injury, medication for pain management, and in some cases, surgical repair of the urethra.

Prognosis and Follow-Up

• The prognosis depends on the severity of the injury but generally, minor injuries heal well with appropriate treatment. Regular follow-up care is crucial to monitor healing and prevent complications.

Complications

• Without proper treatment, complications can include urethral stricture (narrowing), infection, urinary incontinence, or sexual dysfunction.

Lifestyle & Prevention

• Prevention tips include wearing protective gear during sports, cautious driving, and careful technique during catheterization to avoid injury.

When to Seek Professional Help

• Seek immediate medical attention if experiencing severe pain, inability to urinate, persistent blood in urine, or signs of infection such as fever and chills.

Additional Resources

• The American Urological Association (https://www.auanet.org/)
• Urology Care Foundation (https://www.urologyhealth.org/)

Tips for Medical Coders

• Ensure to use the correct code for subsequent encounters only, indicating follow-up care after initial treatment for the urethral injury.
• Avoid coding errors by confirming that documentation specifies the encounter type as subsequent, not initial or sequela.