John J. Bauer, M.D., F.A.C.S.
Counseling and Pre-Op Note (Risks)
Instillation of Medication into the Bladder
Procedure: Intravesical Therapy For Interstitial Cystitis
Chronic Bladder Pain
Options include observation, hydrodilation therapy under anesthesia, and medical therapy such as Elavil and Elmiron.
The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, infection, fever and chills, bladder pain, dysuria, failure of the procedure, potential injury to other surrounding structures, Additional procedures will be necessary. You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.
Physician's Signature: ________________________________ Date: __________________
Patient Signature: __________________________________ Date: __________________
You are about to receive medication into your bladder. This is done by inserting a catheter into the opening of the urethra, then into the bladder. When the catheter is passed into the bladder, the medicine will be passed through the catheter into the bladder. This is called bladder instillation. You will receive your treatment via this method. The usual course of treatment is once a week for six weeks and after a three-week break an additional 3 treatments will be required.
Please be on time for your appointment.
Do not drink fluids for at least 4 hours before you receive your treatment.
Inform your doctor if you felt feverish, tired or had chills since your last treatment or if you have been urinating any bright red blood before your instillation.
Empty your bladder just before the instillation.
The medication will be instilled into your bladder through the catheter. In most cases, the catheter will be removed from the bladder after the instillation. The medication should be retained for at least 15 minutes to obtain the best results. You may be positioned from side to side and back to front while the medication is still in your bladder.
Now that you have retained the medication in your bladder for al least the past 15 minutes, you must know several things:
Sit down on the toilet to urinate and fully empty your bladder.
Wash your hands and genital areas thoroughly after you urinate.
Drink plenty of fluids after your instillation to flush your bladder.