Procedure: CIRCUMCISION

INFORMED CONSENT FOR SURGICAL OPERATION / PROCEDURE

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. _________________ and such assistants and associates as may be selected by him/her to perform the above procedure.

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 understand that circumcision involves surgical removal of the foreskin (prepuce) covering the glans penis.

The procedure may be performed using conventional surgical techniques or electrocautery or stapler

The procedure may be undertaken for:

Phimosis • Recurrent balanitis/balanoposthitis • Paraphimosis (after reduction) • Balanitis xerotica obliterans (BXO) • Recurrent urinary tract infections (selected patients) • Religious/cultural reasons • Other medical indications like suspected malignancy or atypical skin

Any tissue removed may be sent for histopathological examination whenever clinically indicated.

4. Benefits and Indications

The expected benefits include:

  • Relief of phimosis
  • Prevention of recurrent infections
  • Improved penile hygiene
  • Relief of pain during erection or intercourse
  • Reduction in risk of recurrent paraphimosis
  • Facilitation of treatment when premalignant or malignant lesions are suspected

I understand that:

• Symptoms may occasionally persist or recur.

• Additional procedures or revision may become necessary in rare cases.

5. Risks and Complications

I have been informed of possible complications including but not limited to:

General Risks

  • Pain ( temporary)
  • Swelling and bruising ( self-limiting)
  • Bleeding requiring pressure/suturing (1–5%)
  • Infection (1–5%)
  • Anaesthetic complications (rare)
  • Allergic reaction to medications

Procedure-Specific rare Risks

  • Wound infection or delayed healing (2–5%)
  • Wound dehiscence (1–3%)
  • Hematoma
  • Skin oedema
  • Cosmetic undersatisfaction
  • Excessive skin removal
  • Inadequate skin removal requiring revision
  • Meatal irritation or meatal stenosis (rare; <1–2%, higher in children)
  • Skin bridges/adhesions
  • Persistent sensitivity or altered sensation
  • Scar formation
  • Injury to glans penis or urethra (very rare; <0.5%)
  • Need for repeat surgery

Functional Risks

  • Temporary painful erections
  • Temporary discomfort during sexual intercourse
  • Altered penile sensation
  • Cosmetic dissatisfaction

6. Postoperative Course (Explained)

I understand:

* Day-care surgery or overnight admission may be required. • Mild swelling and bruising are common. • Dressing may be removed after 24–48 hours. • Sutures generally dissolve within 2–3 weeks. • Sexual activity and masturbation should be avoided for approximately 4–6 weeks. • Complete healing usually occurs within 4–6 weeks.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Topical steroid therapy (selected cases of phimosis)
  • Preputioplasty
  • Conservative treatment
  • No treatment with associated risks explained

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.

14. 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: __________________