PK 7"\_rels/PK 7"\ docProps/PK 7"\ppt/PK 7"\ ppt/_rels/PK 7"\ ppt/charts/PK 7"\ppt/charts/_rels/PK 7"\ppt/embeddings/PK 7"\ ppt/media/PK 7"\ppt/slideLayouts/PK 7"\ppt/slideLayouts/_rels/PK 7"\ppt/slideMasters/PK 7"\ppt/slideMasters/_rels/PK 7"\ ppt/slides/PK 7"\ppt/slides/_rels/PK 7"\ ppt/theme/PK 7"\ppt/notesMasters/PK 7"\ppt/notesMasters/_rels/PK 7"\ppt/notesSlides/PK 7"\ppt/notesSlides/_rels/PK 7"\99[Content_Types].xml PK 7"\]] _rels/.rels PK 7"\p!docProps/app.xml 0 0 Microsoft Office PowerPoint On-screen Show (16:9) 0 30 30 0 0 false Fonts Used 2 Theme 1 Slide Titles 30 Arial Calibri Office Theme Slide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23Slide 24Slide 25Slide 26Slide 27Slide 28Slide 29Slide 30 PptxGenJS false false false 16.0000 PK 7"\kgrdocProps/core.xml Circumcision PptxGenJS Presentation Prof. Zahid Mahmood Prof. Zahid Mahmood 1 2026-07-12T04:17:46Z 2026-07-12T04:17:46Z PK 7"\5ͨppt/_rels/presentation.xml.rels PK 7"\Oݨ ppt/theme/theme1.xmlPK 7"\]x[[ppt/presentation.xml PK 7"\Xppt/presProps.xml PK 7"\ppt/tableStyles.xml PK 7"\D >00ppt/viewProps.xml PK 7"\H7t!ppt/slideLayouts/slideLayout1.xml PK 7"\ђ77,ppt/slideLayouts/_rels/slideLayout1.xml.rels PK 7"\kQ Q ppt/slides/slide1.xml بِسْمِ اللَّهِ الرَّحْمَٰنِ الرَّحِيمِIn the name of Allah, the Most Gracious, the Most MercifulPK 7"\3 ppt/slides/_rels/slide1.xml.rels PK 7"\.ppt/notesSlides/notesSlide1.xml 1PK 7"\:A*ppt/notesSlides/_rels/notesSlide1.xml.rels PK 7"\ڻ__ppt/slides/slide2.xml CircumcisionIndications, Technique & ComplicationsProf. Zahid MahmoodMBBS, FCPS — General & Laparoscopic SurgeonPK 7"\2- ppt/slides/_rels/slide2.xml.rels PK 7"\ppt/notesSlides/notesSlide2.xml 2PK 7"\xշ*ppt/notesSlides/_rels/notesSlide2.xml.rels PK 7"\SSppt/slides/slide3.xml Did You Know?It is one of the oldest operations known.Millions are done around the world yearly.A tight foreskin in babies is often normal.Never force a child's foreskin back.Bleeding is the commonest early problem.PK 7"\W/ ppt/slides/_rels/slide3.xml.rels PK 7"\K |Őppt/notesSlides/notesSlide3.xml 3PK 7"\9 Y*ppt/notesSlides/_rels/notesSlide3.xml.rels PK 7"\8ñppt/slides/slide4.xml Learning OutcomesDefine circumcision and its indications.Separate normal from pathological phimosis.List the contraindications clearly.Describe the common techniques.Recognise and prevent the complications.PK 7"\` ppt/slides/_rels/slide4.xml.rels PK 7"\vsppt/notesSlides/notesSlide4.xml 4PK 7"\J *ppt/notesSlides/_rels/notesSlide4.xml.rels PK 7"\&0tppt/slides/slide5.xml DefinitionSurgical removal of the foreskin (prepuce).One of the commonest surgical procedures.Done for religious, social and medical reasons.May be performed at any age.Requires care to avoid complications.PK 7"\5 ppt/slides/_rels/slide5.xml.rels PK 7"\W8ppt/notesSlides/notesSlide5.xml 5PK 7"\Qe*ppt/notesSlides/_rels/notesSlide5.xml.rels PK 7"\spppt/slides/slide6.xml Relevant AnatomyThe prepuce covers the glans penis.The frenulum lies on the underside.The frenular artery runs in the frenulum.It is the main source of bleeding.Control it carefully during surgery.PK 7"\ج+ ppt/slides/_rels/slide6.xml.rels PK 7"\zppt/notesSlides/notesSlide6.xml 6PK 7"\=|*ppt/notesSlides/_rels/notesSlide6.xml.rels PK 7"\5'ppt/slides/slide7.xml Physiological PhimosisA tight foreskin is normal in infants.It cannot be retracted at birth.Most become retractile by age five.This alone is not an indication.Never force the foreskin backward.PK 7"\F ppt/slides/_rels/slide7.xml.rels PK 7"\)lppt/notesSlides/notesSlide7.xml 7PK 7"\|g*ppt/notesSlides/_rels/notesSlide7.xml.rels PK 7"\uDppt/slides/slide8.xml Medical IndicationsPathological phimosis with scarring (BXO).Recurrent balanitis or foreskin infection.Recurrent paraphimosis.Recurrent urinary tract infections.Preputial disease or early tumour.PK 7"\6 ppt/slides/_rels/slide8.xml.rels PK 7"\iސppt/notesSlides/notesSlide8.xml 8PK 7"\pO*ppt/notesSlides/_rels/notesSlide8.xml.rels PK 7"\wOVppt/slides/slide9.xml Religious & Social ReasonsPractised in Islam and Judaism.A common cultural and family custom.Often performed in the newborn period.Should still be done safely and cleanly.Informed consent from parents is essential.PK 7"\>$ ppt/slides/_rels/slide9.xml.rels PK 7"\qppt/notesSlides/notesSlide9.xml 9PK 7"\1*ppt/notesSlides/_rels/notesSlide9.xml.rels PK 7"\ڮppt/slides/slide10.xml ContraindicationsHypospadias — the foreskin is needed.Epispadias and other penile anomalies.Uncorrected bleeding disorders.Active local infection — defer surgery.Buried penis or ambiguous genitalia.PK 7"\Ѳ!ppt/slides/_rels/slide10.xml.rels PK 7"\O ppt/notesSlides/notesSlide10.xml 10PK 7"\T+ppt/notesSlides/_rels/notesSlide10.xml.rels PK 7"\!appt/slides/slide11.xml Phimosis vs ParaphimosisPhimosis — foreskin cannot be pulled back.Paraphimosis — foreskin trapped behind the glans.Paraphimosis causes swelling and is an emergency.Reduce a paraphimosis promptly by hand.Circumcision may follow after healing.PK 7"\;!ppt/slides/_rels/slide11.xml.rels PK 7"\s6ӑ ppt/notesSlides/notesSlide11.xml 11PK 7"\O+ppt/notesSlides/_rels/notesSlide11.xml.rels PK 7"\Gԋppt/slides/slide12.xml AnaesthesiaLocal or general anaesthesia may be used.A dorsal penile nerve block is common.A ring block gives good pain relief.Newborns may have local anaesthesia.Adequate pain control is essential.PK 7"\c!ppt/slides/_rels/slide12.xml.rels PK 7"\*)@ ppt/notesSlides/notesSlide12.xml 12PK 7"\Fb+ppt/notesSlides/_rels/notesSlide12.xml.rels PK 7"\Mcppt/slides/slide13.xml Techniques — NewbornSpecial clamps are commonly used.The Plastibell device is popular.Gomco and Mogen clamps are alternatives.They protect the glans during removal.The procedure is quick and clean.PK 7"\x!ppt/slides/_rels/slide13.xml.rels PK 7"\Ї ppt/notesSlides/notesSlide13.xml 13PK 7"\yv+ppt/notesSlides/_rels/notesSlide13.xml.rels PK 7"\"ppt/slides/slide14.xml Techniques — Older Children & AdultsA formal open operation is performed.The foreskin is excised in a sleeve.The frenular artery is tied off.Skin edges are sutured neatly.Careful haemostasis prevents bleeding.PK 7"\O!ppt/slides/_rels/slide14.xml.rels PK 7"\0 ppt/notesSlides/notesSlide14.xml 14PK 7"\?ݤ+ppt/notesSlides/_rels/notesSlide14.xml.rels PK 7"\:5ppt/slides/slide15.xml ComplicationsBleeding is the commonest early problem.Wound infection may occur.Meatal stenosis can develop later.Too much or too little skin removed.Rarely, injury to the glans or urethra.PK 7"\*R!ppt/slides/_rels/slide15.xml.rels PK 7"\Qz ppt/notesSlides/notesSlide15.xml 15PK 7"\$Q+ppt/notesSlides/_rels/notesSlide15.xml.rels PK 7"\Bᕖppt/slides/slide16.xml Health AdvantagesFewer urinary infections in infancy.Lower risk of penile cancer.Reduced spread of some infections.Prevents phimosis and paraphimosis.Easier hygiene of the glans.PK 7"\ !ppt/slides/_rels/slide16.xml.rels PK 7"\  ppt/notesSlides/notesSlide16.xml 16PK 7"\ y+ppt/notesSlides/_rels/notesSlide16.xml.rels PK 7"\\Mޖppt/slides/slide17.xml AftercareGive simple analgesia for pain.Keep the area clean and dry.Watch closely for any bleeding.Avoid trauma while it heals.Healing takes about one to two weeks.PK 7"\檋!ppt/slides/_rels/slide17.xml.rels PK 7"\r. ppt/notesSlides/notesSlide17.xml 17PK 7"\BI+ppt/notesSlides/_rels/notesSlide17.xml.rels PK 7"\S9ppt/slides/slide18.xml Take-Home MessageCircumcision removes the foreskin.Infant phimosis is usually normal — do not force.Never circumcise a boy with hypospadias.Bleeding from the frenular artery is commonest.Operate cleanly and control bleeding well.PK 7"\Yh!ppt/slides/_rels/slide18.xml.rels PK 7"\ ppt/notesSlides/notesSlide18.xml 18PK 7"\N+ppt/notesSlides/_rels/notesSlide18.xml.rels PK 7"\6`ppt/slides/slide19.xml AssessmentTen Single-Best-Answer QuestionsPK 7"\~!ppt/slides/_rels/slide19.xml.rels PK 7"\0[ ppt/notesSlides/notesSlide19.xml 19PK 7"\i+ppt/notesSlides/_rels/notesSlide19.xml.rels PK 7"\Hppt/slides/slide20.xml MCQ 1A healthy 2-year-old boy has a foreskin that cannot be fully retracted, but he voids normally with no symptoms. The correct advice is:A. Urgent circumcisionB. Forcible retractionC. Reassurance — this is normalD. Long-term antibioticsE. Immediate steroid then surgeryKey: CPK 7"\g_!ppt/slides/_rels/slide20.xml.rels PK 7"\7 ppt/notesSlides/notesSlide20.xml 20PK 7"\SB+ppt/notesSlides/_rels/notesSlide20.xml.rels PK 7"\Gw~~ppt/slides/slide21.xml MCQ 2A boy returns two hours after circumcision with blood soaking the dressing. The commonest early complication of circumcision is:A. InfectionB. BleedingC. Meatal stenosisD. Glans injuryE. AdhesionsKey: BPK 7"\z!ppt/slides/_rels/slide21.xml.rels PK 7"\89| ppt/notesSlides/notesSlide21.xml 21PK 7"\HΩ+ppt/notesSlides/_rels/notesSlide21.xml.rels PK 7"\˔ߜppt/slides/slide22.xml MCQ 3During a circumcision, brisk bleeding comes from the underside of the penis. The vessel most likely responsible is the:A. Dorsal artery of penisB. Frenular arteryC. Deep artery of penisD. External pudendal veinE. Bulbar arteryKey: BPK 7"\dV!ppt/slides/_rels/slide22.xml.rels PK 7"\cQc ppt/notesSlides/notesSlide22.xml 22PK 7"\aeZ+ppt/notesSlides/_rels/notesSlide22.xml.rels PK 7"\ ppt/slides/slide23.xml MCQ 4A newborn is booked for circumcision, but the urethral opening is found on the ventral shaft. Circumcision is contraindicated because:A. He is too youngB. The foreskin is needed for later repairC. High risk of infectionD. Bleeding riskE. Religious reasonsKey: BPK 7"\A!ppt/slides/_rels/slide23.xml.rels PK 7"\] ppt/notesSlides/notesSlide23.xml 23PK 7"\ ~t+ppt/notesSlides/_rels/notesSlide23.xml.rels PK 7"\oݘppt/slides/slide24.xml MCQ 5A 9-year-old has a white, scarred, rigid non-retractile foreskin (balanitis xerotica obliterans). The best management is:A. ReassuranceB. CircumcisionC. Forcible retractionD. Topical antibiotic onlyE. Observation for yearsKey: BPK 7"\Y!ppt/slides/_rels/slide24.xml.rels PK 7"\`z ppt/notesSlides/notesSlide24.xml 24PK 7"\8+ppt/notesSlides/_rels/notesSlide24.xml.rels PK 7"\Gqppt/slides/slide25.xml MCQ 6A retracted foreskin is stuck behind the glans, which is now swollen and painful. The immediate management is:A. Urgent circumcisionB. Manual reduction of the foreskinC. Antibiotics onlyD. CatheterisationE. ObservationKey: BPK 7"\̜|g!ppt/slides/_rels/slide25.xml.rels PK 7"\Y ppt/notesSlides/notesSlide25.xml 25PK 7"\#+ppt/notesSlides/_rels/notesSlide25.xml.rels PK 7"\q||ppt/slides/slide26.xml MCQ 7Months after circumcision, a boy has a narrow, high-pressure urinary stream. The likely late complication is:A. Urethral fistulaB. Meatal stenosisC. Recurrent phimosisD. HydroceleE. EpididymitisKey: BPK 7"\5b?!ppt/slides/_rels/slide26.xml.rels PK 7"\Aʑ ppt/notesSlides/notesSlide26.xml 26PK 7"\${+ppt/notesSlides/_rels/notesSlide26.xml.rels PK 7"\QlNppt/slides/slide27.xml MCQ 8Which of the following is a recognised long-term benefit of circumcision?A. Increased fertilityB. Reduced risk of penile cancerC. Prevention of testicular torsionD. Taller statureE. Prevents undescended testisKey: BPK 7"\PG!ppt/slides/_rels/slide27.xml.rels PK 7"\W  ppt/notesSlides/notesSlide27.xml 27PK 7"\e+ppt/notesSlides/_rels/notesSlide27.xml.rels PK 7"\/ppt/slides/slide28.xml MCQ 9For circumcision under local anaesthesia, a commonly used technique to numb the penis is a:A. Spinal blockB. Dorsal penile nerve (ring) blockC. Femoral nerve blockD. General anaesthesia onlyE. Topical cream aloneKey: BPK 7"\ [R]!ppt/slides/_rels/slide28.xml.rels PK 7"\\ ppt/notesSlides/notesSlide28.xml 28PK 7"\i+ppt/notesSlides/_rels/notesSlide28.xml.rels PK 7"\BGGppt/slides/slide29.xml MCQ 10A commonly used device for safe newborn circumcision is the:A. Foley catheterB. PlastibellC. Bard clampD. Doyen retractorE. Bugbee electrodeKey: BPK 7"\->w!ppt/slides/_rels/slide29.xml.rels PK 7"\zx ppt/notesSlides/notesSlide29.xml 29PK 7"\(Lk+ppt/notesSlides/_rels/notesSlide29.xml.rels PK 7"\xRppt/slides/slide30.xml Thank You“Even the smallest operation deserves the greatest care.Respect the child and the family's trust,and remember — good surgery is measurednot by its size, but by its safety.”Prof. Zahid MahmoodPK 7"\*!ppt/slides/_rels/slide30.xml.rels PK 7"\ q) ppt/notesSlides/notesSlide30.xml 30PK 7"\+ppt/notesSlides/_rels/notesSlide30.xml.rels PK 7"\K !ppt/slideMasters/slideMaster1.xml PK 7"\N),ppt/slideMasters/_rels/slideMaster1.xml.rels PK 7"\6TT!ppt/notesMasters/notesMaster1.xml 7/23/19Click to edit Master text stylesSecond levelThird levelFourth levelFifth level‹#›PK 7"\s **,ppt/notesMasters/_rels/notesMaster1.xml.rels PK 7"\_rels/PK 7"\ $docProps/PK 7"\Kppt/PK 7"\ mppt/_rels/PK 7"\ ppt/charts/PK 7"\ppt/charts/_rels/PK 7"\ppt/embeddings/PK 7"\ ppt/media/PK 7"\Bppt/slideLayouts/PK 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