Rectocele

This code represents a rectocele, which is a herniation of the rectum into the posterior vaginal wall. It occurs when the rectovaginal septum weakens, allowing the rectum to bulge forward. Patients may experience symptoms such as difficulty with defecation, a feeling of incomplete evacuation, or vaginal pressure.

Use this code when documentation clearly indicates a rectocele without mention of uterine prolapse. This diagnosis is typically supported by physical examination findings, such as a visible bulge in the posterior vaginal wall, and patient-reported symptoms. It is often identified during a pelvic exam or defecography.

• Do not code this with N81.2-N81.4 (rectocele with uterine prolapse); choose the combined code if uterine prolapse is also present.
• Differentiate from K62.3 (rectal prolapse), which involves the rectum protruding through the anus, not into the vagina.
• Consider additional codes for associated symptoms (e.g., constipation, dyspareunia) if documented and clinically significant.