Anterior and Posterior Colpography (Front–Back Repair) Patient Consent Form
Obstetrics and Gynecology Specialist
Dr. Ebru COŞKUN
ANTERIOR AND POSTERIOR COLPOGRAPHY (FRONT–BACK REPAIR) PATIENT CONSENT FORM
DEAR PATIENT / DEAR LEGAL GUARDIAN
You have the right to be informed about your health condition and any medical, surgical, or diagnostic procedures recommended to you, as well as their alternatives, benefits, risks, and possible harms—and to accept, reject, or stop these procedures at any stage.
This document, which we ask you to read and understand, is not meant to frighten or discourage you from treatment. Its purpose is to involve you in decisions regarding your health, inform you clearly, and obtain your consent.
1. Expected Benefits of the Procedure
This procedure is commonly performed on women who have prolapse in the anterior and posterior vaginal walls.
The prolapse may involve the bladder, rectum, upper part of the vagina, or all these structures.
During this surgery, the patient’s own natural tissues are used to repair and strengthen the muscle layers.
Improvements expected after the procedure include:
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The feeling of a mass during urination or defecation
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The need to push the vagina with a finger to evacuate stool
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Air leakage during intercourse
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Discomfort or difficulty during intercourse due to prolapse
2. Consequences of Not Undergoing the Procedure
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Existing symptoms may worsen
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Difficulty urinating may occur and catheter placement may be required
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As prolapse progresses, ulcers may develop, causing pain and discomfort
3. Alternatives to the Procedure
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Pelvic floor exercises (Kegel exercises)
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Lifestyle changes
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Diet modification and weight loss
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Other: ……………………………………………….
4. Risks and Possible Complications of the Procedure
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Bleeding from major vessels may occur and may require blood transfusion
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Infection at the surgical site or urinary tract
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Injury to the ureter, bladder, or intestines
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Difficulty urinating after surgery; a catheter may be required
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You may be asked to insert your own catheter until normal urination returns
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Postoperative stress incontinence (urine leakage during coughing, sneezing, or physical strain)
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Pre-existing but undetected bladder weakness may become apparent after surgery
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Formation of a fistula between the vagina and bladder
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Formation of a rectovaginal fistula, causing stool leakage into the vagina
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Changes in bladder or bowel habits
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Pain during sexual intercourse
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Recurrence of prolapse over time
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Narrowing or shortening of the vagina, potentially causing pain during intercourse
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Obese patients are at higher risk of wound infection, lung infection, heart/lung complications, and thrombosis
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Smokers have an increased risk of wound infection, lung infection, cardiac and pulmonary complications, and thrombosis
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Untreated constipation after the procedure can reduce the long-term success of the operation and cause recurrence of symptoms
5. Estimated Duration of the Procedure
The procedure lasts at least 1 hour, depending on surgical conditions.
Patient Declaration
I have read the information above, listened to my doctor’s explanations, asked all questions, and understood the risks, complications, and purpose of this medical/surgical procedure.
I understand that I am not obligated to accept treatment and may stop the procedure at any stage.
With full awareness and of my own free will, I consent to the procedure for the benefit of my health.
DATE: ……………… / ……………… / 20……
TIME: ……………
PHYSICIAN PROVIDING INFORMATION / PERFORMING THE PROCEDURE
PATIENT or LEGAL REPRESENTATIVE
WITNESS