Patient Name:

Age:

Date:

Procedure: Hydrodilation under anesthesia, cystoscopy, possible bladder biopsies

Indications:

Patient suffers from severe irritable bladder symptoms that may be secondary to Interstitial Cystitis.

Alternatives:

Options include: observation, medical therapy, hydrodilation therapy, DMSO bladder instillation, electrical stimulation/biofeedback/behavior therapy, and surgical procedures (such as urinary diversion, bladder augmentation, and cystectomy with diversion)

Risks/Complications:

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, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.

The specific risks of this procedure include, but are not limited to: perforation of the bladder worsening of the bladder irritability or pelvic pain.

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: __________________