Wednesday, 8 August 2012


Consent of Patient’s agreement for Urogynaecology & Gynaecological

Investigation, Treatment & Surgery


Name:----------------------------------  MRN/IC NO:-----------------------------------------
 Name of proposed procedure:

  • OTHER UROGYNAECOLOGY PROCEDURES:____________________________________________________
  • HER GYNAECOLOGICAL PROCEDURES:____________________________________________________
 A. Statement of health profession: I have explained the procedure to the patient. In particular, I have explained

1. The intended benefits:  (tick where applicable)
§  To improve or resolve the symptoms of ‘stress urinary incontinence’ and ‘prolapse‘
§  To remove uterus to overcome uterine related pathalogy
§  Others (please specify) ________________________________________________________

2. Possible serious risks:
§  Damage to the bladder and/or Ureter and/or long term disturbance to the bladder function
inapproximately 2% of cases
§  Damage to bowel in approximately in 1% cases
§  Haemorrhage requiring blodd transfusion  in about 2-3% cases
§  Return to the operating theatre for additional stitches or to control bleeding or for open surgery
§  Pelvic abscess/infection approximately in 1% cases
§  Venous thrombosis or pulmonary embolism  approximately in 1% patients
§  Dyspareunia ( painful sexual intercourse)
§  Failure to achieve the desired results or recurrence of prolapse or urinary incontinence
§  Sling complications eg. Erosions, mesh protrusion in about  0.7%

3.Possible frequently occurring risks:
§  Urinary retention in about 3% of patients, may need excision of the tape if unable to void properly
§  Vaginal bleeding, discharge or infection
§  Frequency of micturition, nocturia and urgency in about 7% of patients
§  Wound infection – up to 15% especially in patients with risk factors
§  Pain, may require analgesics

4. Any extra emergency procedures which may become necessary during the procedure:
§  Blood transfusion – may be required in approximately 2 in every 1000 women undergoing this procedure
§  Removal of ovaries for unsuspected disease during the surgery
§  Conversion to abdominal approach due to anticipated difficulties or to undertake repair of any injury to bladder ,ureter, bowel or major blood vessels in approximately 4%- 8% cases
§  Other procedures (please specify) ___________________

I have explained that in obese women those with underlying medical problems or who have had previous surgery (ex: Caesarean section), the quoted risks may be higher.

I have also discuss the benefits and risks of any available treatments including physiotherapy, ring pressary insertion and also option of no treatment

Signature:_____________________________________             Date:_____________________
Consultant Urogynaecologist

Signature of patient: ____________________________                Date:_____________________

 Patients Name:_________________________________
B. Statement of interpreter (where appropriate)
I have interpreted the information above to the patient to the best of my ability and in a way which I believe she can understand.

Signature:_____________________ Name:_______________________________ Date:______________

C. Statement of patient
Please read this form carefully. You must also read the front page carefully which describes the benefits and risks of the proposed treatment. if you have any questions, please ask us as we are here to help you. You have the right to change your mind at any time, including after you signed this form.

1.    I have read the previous sheet and understood the benefits                                       YES             NO
      and the risks of the proposed treatment or surgery                                                                                                                                     
2.    I agree to the procedure described by the doctor                                                        YES              NO

3.    I understand that you cannot give me a guarantee that a particular person                 YES             NO  
       will perform the procedure. The person will, however has the
       appropriate experience to perform the surgery.

4.   I understand that I have the opportunity to discuss the details of anaesthesia            YES              NO
      with an anaesthetist before the procedure, unless the urgency of my situation
      prevents this.

5.  I understand that any procedure in addition to those described on this                         YES             NO   
     form will only be carried out if it is necessary to save my life or to prevent serious
     harm(complications) to my health

6.  I have been told about the additional procedures which may become necessary        YES             NO  
     during my treatment

7.  I have been given a patient information leaflet                                                                  YES            NO   

8.  I have listed below procedures which I do not wish to be carried out                              YES            NO
     without further discussion
Signature:_____________________ Name:_________________________ Date:______________

D. Witness
A witness should sign below if she/he has witnessed the patient's signature above. Parents or guardians should sign below behalf of patients under the age if legal consent (18 years and above)

Signature:_____________________ Name:_________________________ Date:______________
Relationship to patient: __________________

E. Confirmation of consent
This section to be completed when the patient admitted for a procedure has sign the form in advance. On behalf of the team treating the patient, I have confirmed with the patient that she has no further questions and wishes the procedure to go ahead.

Signature:_____________________ Name:_________________________ Date:______________