S37.422D Contusion of ovary, bilateral, subsequent encounter

Name of the Condition

• Contusion of ovary, bilateral, subsequent encounter

Summary

Contusion of the ovary, bilateral, subsequent encounter refers to bruising or minor tissue damage to both ovaries resulting from trauma, documented during a follow-up visit. This condition typically involves localized pain, swelling, or bleeding, with the extent of injury and clinical impact depending on the force of the trauma and whether associated pelvic structures are affected. The subsequent encounter indicates ongoing management or monitoring after the initial injury.

Causes

Blunt or penetrating trauma to the abdomen or pelvis, such as from motor vehicle accidents, falls, or direct impact to the lower abdomen. Surgical procedures involving pelvic organs, including gynecologic surgeries, may also cause this injury. Penetrating injuries, though less common, can lead to this condition if both ovaries are directly affected.

Risk Factors

• Participation in contact sports or activities with a high risk of abdominal or pelvic trauma.
• Pre-existing ovarian conditions, such as cysts or tumors, which may increase vulnerability to injury.
• Advanced age, which may reduce tissue resilience.
• Certain occupations or lifestyles involving physical risk.

Symptoms

• Pelvic or lower abdominal pain, often localized to the affected area.
• Tenderness or swelling in the pelvic region.
• Possible vaginal bleeding or spotting.
• Nausea or vomiting in some cases.
• Signs of shock in severe cases.

Diagnosis

Physical examination to assess tenderness, swelling, or external trauma. Imaging studies, such as ultrasound, CT scan, or MRI, to visualize ovarian damage. Laboratory tests to evaluate for internal bleeding or organ dysfunction. Review of prior imaging or clinical notes to confirm the bilateral nature of the injury and the subsequent encounter context.

Treatment Options

Conservative management with rest, pain relief, and monitoring for complications. Surgical intervention may be required if significant bleeding, organ damage, or other complications arise. Follow-up care to assess healing and ovarian function.

Prognosis and Follow-Up

Prognosis depends on the severity of the injury and response to treatment. Most cases resolve with conservative care, but bilateral involvement may increase the risk of long-term complications. Regular follow-up to monitor for persistent pain, functional impairment, or signs of infection.

Complications

Potential for ovarian cyst formation, chronic pain, or reduced fertility. Risk of internal bleeding or infection if the injury is severe. Long-term ovarian dysfunction or damage in rare cases.

Lifestyle & Prevention

Avoid activities with high risk of abdominal trauma. Use protective gear during contact sports. Seek prompt medical evaluation after pelvic or abdominal injuries. Follow post-injury care instructions to support healing.

When to Seek Professional Help

Severe or worsening pelvic pain, signs of shock (e.g., dizziness, rapid heartbeat), heavy vaginal bleeding, or fever. Persistent symptoms after initial treatment may require further evaluation.

Tips for Medical Coders

Document the bilateral nature of the contusion and the subsequent encounter context clearly. Include details on the mechanism of injury, clinical findings, and any imaging or laboratory results supporting the diagnosis. Ensure the encounter is coded as subsequent (D) to reflect follow-up care.