N40.1
Benign prostatic hyperplasia with lower urinary tract symptoms
Clinical Classification Guidelines
Use Additional Code
- code for associated symptoms, when specified:
- incomplete bladder emptying (R39.14)
- nocturia (R35.1)
- straining on urination (R39.16)
- urinary frequency (R35.0)
- urinary hesitancy (R39.11)
- urinary incontinence (N39.4-)
- urinary obstruction (N13.8)
- urinary retention (R33.8)
- urinary urgency (R39.15)
- weak urinary stream (R39.12)
Inclusion Terms
- Enlarged prostate with LUTS
Medical Intelligence & Overview
Benign prostatic hyperplasia (BPH) is a common condition affecting aging men, characterized by the non-cancerous enlargement of the prostate gland. When this enlargement leads to lower urinary tract symptoms (LUTS), it can significantly impact daily life. The ICD-10 code N40.1 specifically refers to cases where BPH is accompanied by LUTS, highlighting the clinical relevance of urinary difficulties associated with prostate growth.
Causes & Symptoms
Clinical Causes: Age-related hormonal changes, particularly a decline in testosterone levels Increased number of prostate cells leading to gland enlargement Genetic predisposition to prostate growth Lifestyle factors such as obesity and lack of physical activity Chronic inflammation or infections of the prostate Dietary factors, including high-fat diets or certain nutrients
Key Symptoms: Frequent urination, especially at night (nocturia) Weak or interrupted urine flow Urgency to urinate Difficulty starting urination A feeling of incomplete bladder emptying Straining during urination Reduced force of urine stream
Diagnostic & Treatment
Diagnosis Path: Diagnosis of BPH with LUTS involves a combination of medical history, physical examination, and diagnostic tests. A healthcare provider typically performs a digital rectal exam (DRE) to assess prostate size and texture. Additional assessments may include:
Treatment Protocols: Treatment options aim to relieve symptoms and prevent complications. Approaches can vary based on symptom severity, prostate size, and overall health. Common treatments include:
Clinical Advice & FAQs
Billing Guidance
Is N40.1 a billable ICD-10 code?
Yes, N40.1 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.
Documentation
How do I report N40.1?
Clinical documentation must specify the nature of Benign prostatic hyperplasia with lower urinary tract symptoms and any associated comorbidities for accurate reporting.
Cite this Clinical Reference