Urodynamic Study Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Urodynamic Study (UDS) ± Video Urodynamics

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

A small catheter is placed into the bladder and another may be placed in the rectum or vagina to measure pressures.

The bladder is filled with sterile fluid while sensation, capacity, pressure, leakage and bladder emptying are assessed.

X-ray imaging may be performed for video urodynamics.

4. Benefits and Indications

The procedure may be performed for:

• Evaluate bladder and urethral function
• Determine the cause of urinary symptoms
• Guide appropriate treatment

The intended benefits include:

• Accurate diagnosis of bladder and urethral dysfunction
• Better treatment planning
• Avoidance of unnecessary surgery or medications
• Assessment of treatment outcomes where indicated

5. Risks and Complications

• Common
  • Temporary catheter discomfort
  • Mild burning
  • Transient blood in urine
  • Urinary urgency
• Less Common
  • UTI requiring antibiotics
  • Temporary difficulty passing urine
  • Vasovagal episode
• Rare but Serious
  • Retention requiring catheterization
  • Significant bleeding
  • Allergic reaction
  • Worsening symptoms and sepsis, very rarely

6. Postoperative Course

I understand that:

• The procedure usually takes 30–60 minutes.
• Daycare surgery or overnight admission may be required.
• Mild burning, urinary frequency or slight blood staining may occur for 24–48 hours. Adequate hydration is advised.

7. Alternatives to Procedure

I have been informed of alternatives including:

• Clinical assessment
• Bladder diary
• Uroflowmetry and post-void residual
• Imaging
• Cystoscopy where indicated

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: _________________________________________