Procedure: FRENULOPLASTY

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 (Explained)

I understand that frenuloplasty is a surgical procedure performed to release and reconstruct the penile frenulum, which is the skin attached very near to the urinary meatus.

The procedure may involve division and reconstruction of the frenulum using absorbable sutures.

The procedure is performed for:

* Frenulum breve • Recurrent frenular tears • Pain during erection/intercourse • Bleeding during intercourse • Sexual dysfunction related to a short frenulum

Circumcision may become necessary if adequate correction cannot otherwise be achieved or if significant foreskin pathology is identified.

Excised tissue may be sent for histopathological examination when indicated.

4. Benefits and Indications

Benefits include:

  • Relief of painful erections
  • Prevention of recurrent tearing
  • Reduction in bleeding during intercourse
  • Improved sexual function
  • Preservation of foreskin where feasible

I understand that:

* Complete symptom relief may not occur in some cases.

• Additional surgery, including circumcision, may become necessary.

• Cosmetic appearance cannot be guaranteed.

6. Risks and Complications

General Risks

  • Bleeding (1–3%)
  • Infection (1–5%)
  • Pain
  • Swelling
  • Anaesthetic complications

Procedure-Specific Risks

  • Wound dehiscence (2–5%)
  • Persistent short frenulum
  • Scar formation
  • Cosmetic dissatisfaction
  • Altered penile sensation
  • Pain during intercourse
  • Dyspareunia
  • Need for circumcision
  • Need for revision surgery
  • Injury to glans or urethra (very rare)

Functional Risks

  • Temporary discomfort during erections
  • Temporary abstinence from sexual activity
  • Persistent symptoms despite surgery

7. Postoperative Course

I understand:

* Usually a day-care procedure. • Mild swelling and bruising are expected. • Sutures dissolve within 2–4 weeks. • Good local hygiene is essential. • Sexual intercourse and masturbation should be avoided for approximately 4–6 weeks. • Complete healing usually occurs within 3–6 weeks.

8. Alternatives

  • Observation
  • Conservative management
  • Circumcision
  • No treatment

9. Anaesthesia and Pain Management

Risks of local/regional/general anaesthesia have been discussed.

10. Photography / Data Use

I consent to:

□ Medical photography/video

□ Anonymous use of clinical information for education/research

11. Intraoperative Decision Consent

I authorize extension or modification of the procedure if clinically indicated.

This includes conversion to circumcision if required for safe and definitive treatment.

12. Team-Based Care

Qualified assistants and residents may participate under supervision.

13. Patient Statement

I confirm that:

* I have understood the procedure. • Risks, benefits and alternatives have been explained. • My questions have been answered. • 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: __________________