Urethral Dilatation Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Urethral Dilatation

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

The narrowed urethra is gradually stretched using sterile dilators under appropriate anaesthesia.

Cystoscopy may also be performed to assess the urethra and bladder.

A urinary catheter may be inserted temporarily.

4. Benefits and Indications

The procedure may be performed for female urethral stricture/narrowing causing:

• Obstructive urinary symptoms
• Recurrent UTI
• Incomplete bladder emptying
• Urinary retention

The intended benefits include:

• Improved urinary flow
• Better bladder emptying
• Relief of obstructive symptoms
• Reduction in recurrent UTI

Symptom relief may be temporary and repeat dilatation may be required.

5. Risks and Complications

• Common
  • Mild bleeding
  • Burning during urination
  • UTI
  • Temporary discomfort
• Less Common
  • Temporary retention
  • Recurrent narrowing
  • False passage
  • Need for repeat dilatation
• Rare but Serious
  • Urethral perforation
  • Bladder injury
  • Significant bleeding
  • Sepsis
  • Urinary incontinence
  • Anaesthetic complications

6. Postoperative Course

I understand that:

• Day care or overnight admission may be required.
• Mild dysuria and haematuria may occur for 24–48 hours.
• Adequate fluid intake and follow-up are advised. A catheter may remain for 24–72 hours depending on operative findings.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Observation
• Intermittent self-catheterization
• Endoscopic urethrotomy
• Female urethroplasty
• Long-term catheter drainage
• No treatment

8. Anaesthesia and Pain Management

I understand the risks associated with local, regional, or general anaesthesia.

Pain management options have been explained.

9. Photography / Data Use

I consent to:

☐ Medical photography/video for academic purposes

☐ Use of anonymized clinical data

10. Intraoperative Decision Consent

I authorize the surgeon to perform additional procedures considered necessary if unexpected findings arise during surgery.

11. Team-Based Care

I understand that supervised residents, fellows, or assistants may participate.

12. Patient Statement

I confirm that:

• The nature of surgery has been explained.
• Risks, benefits, and alternatives have been explained.
• My questions have been answered satisfactorily.
• I voluntarily consent.

Patient 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: _________________________________________