PTNS Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Percutaneous Tibial Nerve Stimulation (PTNS)

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 fine needle electrode is inserted near the tibial nerve at the ankle.

Mild electrical stimulation is delivered for approximately 30 minutes to modulate bladder nerve pathways.

Multiple treatment sessions over several weeks are usually required.

4. Benefits and Indications

The procedure may be performed for:

  • Refractory overactive bladder
  • Urgency
  • Frequency
  • Urge urinary incontinence
  • Selected bladder dysfunction after inadequate response to conservative measures and medications

The intended benefits include:

  • Reduction in urinary urgency
  • Reduction in frequency
  • Reduction in nocturia
  • Reduction in urge incontinence
  • Improved quality of life

Complete symptom relief cannot be guaranteed.

5. Risks and Complications

  • Temporary needle-site pain/discomfort
  • Bruising
  • Minor bleeding
  • Skin irritation
  • Numbness or tingling
  • Temporary foot discomfort
  • Infection, rarely
  • Vasovagal episode, rarely
  • Failure to improve symptoms

6. Postoperative Course

I understand that:

  • An initial course usually consists of 12 weekly sessions, followed by maintenance treatment in selected patients.
  • Patients usually return to normal activities immediately after treatment. Benefits may diminish if maintenance sessions are discontinued.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Behavioural therapy
  • Pelvic floor exercises
  • Medications
  • Intradetrusor botulinum toxin
  • Sacral neuromodulation
  • Observation where appropriate

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: _________________________________________

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