Inflatable Penile Prosthesis (IPP) Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Inflatable Penile Prosthesis (IPP)

1. Patient Identification

I, ______________________________ (patient/next of kin/legal guardian), aged ____ years, in my full senses, voluntarily authorize and give my complete consent for performance of the following procedure(s)/operation(s)/treatment(s):

Procedure: _______________________________
Diagnosis: ________________________________
Major illness & comorbidities: ________________________________

2. Authorization for Procedure

I authorize Dr. __________________ to perform the above procedure, along with such assistants and associates as may be selected by him/her.

I understand that members of the surgical team, including residents or trainees under appropriate supervision, may perform parts of the procedure according to their training and competence.

3. Nature of Procedure

I have been informed that I have a condition of erectile dysfunction that has not responded adequately to, or is unsuitable for, non-surgical treatment options including oral medications, injection therapy, vacuum erection devices, or other conservative measures.

I understand that this procedure involves surgical implantation of a three-piece inflatable penile prosthesis into the corpora cavernosa.

A fluid reservoir is placed in the pelvis near the urinary bladder and a pump is positioned within the scrotum near the testis.

The device is manually inflated for intercourse and deflated afterwards.

The procedure is intended to treat erectile dysfunction refractory to medical therapy.

4. Benefits and Indications

  • Restoration of erectile function for penetrative intercourse
  • High patient and partner satisfaction
  • Long-term treatment for medically refractory erectile dysfunction
  • May improve quality of life and sexual confidence

5. No Guarantee Clause

I understand that no guarantee has been given regarding restoration of sexual satisfaction or device longevity.

Mechanical failure, revision surgery or replacement may be required in the future.

6. Risks and Complications

General Risks

  • Bleeding/hematoma (2–10%)
  • Infection (1–3%; higher in diabetics, spinal cord injury, immunocompromised)
  • Pain and wound complications
  • Anaesthetic complications (rare)

Procedure-Specific Risks

  • Device infection requiring removal
  • Mechanical failure over time
  • Erosion into urethra or skin
  • Cylinder crossover or malposition
  • Reservoir or pump migration
  • Penile shortening/perceived loss of length
  • Persistent pain
  • Revision or replacement surgery
  • Injury to urethra, bladder or surrounding structures (rare)
  • Unsatisfactory cosmetic or functional outcome

7. Postoperative Course

Hospital stay is usually 1–2 days.

A urinary catheter may be required temporarily.

Scrotal swelling and discomfort are expected.

Device activation is usually performed after 4–6 weeks.

Sexual activity should be avoided until cleared by the surgeon.

8. Alternatives to Procedure

  • Oral PDE5 inhibitors
  • Vacuum erection device
  • Intracavernosal injection therapy
  • Malleable penile prosthesis
  • Penile revascularization (selected cases)
  • No treatment

9. Blood Transfusion Consent

I consent to blood/blood product transfusion if required and understand the rare risks including infection and allergic reactions.

10. Anaesthesia and Pain Management

I understand the risks of general/regional anaesthesia and available pain management options.

11. Photography / Data Use

I consent to medical photography/video and anonymised use of my clinical information for academic/research purposes.

12. Intraoperative Decision Consent

I authorize the surgical team to modify or extend the procedure depending on intraoperative findings, including changing prosthesis type or abandoning implantation if unsafe.

13. Team-Based Care

I understand that qualified assistants/trainees may participate under appropriate supervision.

14. Patient Statement

I confirm that I have understood the procedure, risks, benefits and alternatives.

My questions have been answered, and I give consent voluntarily.

Patient/Attendant to write in own handwriting:

“I have understood the procedure, risks, benefits and alternatives explained to me in a language I understand.”

Signatures

Patient Name & Signature: ______________________________________

Date: ____________________ Time: ____________________

Doctor Name & Signature: ______________________________________

Date: ____________________ Time: ____________________

Witness Name & Signature: ____________________________________

Contact No.: ______________________________

ATTENDANT CONSENT (If applicable)

Reason patient unable to consent:

Attendant Name: __________________________________________

Relationship: _____________________________________________

Signature: ________________________________________________

Contact No.: ______________________________________________

INTERPRETER STATEMENT (If applicable)

I confirm an accurate explanation in understandable language.

Name: _________________________________________________

Signature: ______________________________________________

Contact: ________________________________________________

HIGH-RISK CONSENT (If applicable)

High-risk factors explained due to:

Patient Signature: ________________________________________

Doctor Signature: _________________________________________

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