Frenulum Breve

Frenulum breve (short frenulum) is a shortened or tight frenulum, the fold of tissue connecting the ventral glans to the prepuce. It restricts retraction of the foreskin and causes ventral curvature of the glans when the foreskin is retracted.

It may be congenital, as part of normal variation of penile structure (in 1 to 5 percent of boys). It may be acquired through scarring after balanoposthitis, lichen sclerosus (balanitis xerotica obliterans), trauma or previous frenulum tears with intercourse.

It is distinguished from phimosis (narrowing of the preputial opening) and from hypospadias (with a deficient ventral foreskin).

In adult men, it causes pain, tearing and bleeding at intercourse ("frenulum tear"). It may cause partial or complete rupture of the frenular artery with significant bleeding.

Complications:

• recurrent frenular tears with scarring
• painful erections
• dyspareunia (for the partner)
• difficulty with intercourse
• balanitis
• psychological distress

• A visibly short, tight, taut frenulum with the foreskin retracted, which pulls the glans downward (ventral tethering), with a tendency for the glans to deviate ventrally on erection; the foreskin cannot be fully retracted behind the corona, or retraction is painful.
• Pain, tightness and discomfort during erection, masturbation or intercourse.
• Frenular tears with bleeding (the frenular artery may bleed profusely and persistently) at intercourse, and scarring.
• Fibrous changes or white fibrous bands from recurrent injury.
• Normal retractability of the foreskin distal to the frenulum (the dorsal prepuce retracts) so that the foreskin retracts incompletely.
• In boys, difficulty with retraction, ballooning of the foreskin on voiding, and parental concern; usually not a problem, as the foreskin is physiologically non-retractile up to age 3 to 5 years.

• Clinical examination: gentle retraction of the foreskin; observe the frenulum (tight band, hypopigmentation, scarring), the glans deviating ventrally, and a normal urethral meatus; examination of the erect penis (or with the patient's reports) in adults.
• Exclude phimosis, lichen sclerosus (white scarring, pallor, biopsy), balanitis, and hypospadias (position of meatus).
• Swabs or biopsy only if inflammation or suspicious skin changes are present.
• Assess for sexually transmitted infection if there is a history of ulceration.

• Observation and reassurance: in young boys, the frenulum is often short but not significant, and the foreskin separates naturally. Do not force retraction.
• Conservative stretching in mild cases in adolescents and men: gentle, gradual stretching of the frenulum with the foreskin retracted over 4 to 8 weeks, with lubrication, after warm bathing. Success is about 50 to 70 percent in mild cases.
• Add topical corticosteroid if there is scarring or inflammation (betamethasone 0.05 percent or hydrocortisone 1 percent applied twice daily for 4 to 6 weeks).
• Frenulotomy (simple division) is indicated for symptomatic cases. Use local anaesthetic (lidocaine 1 percent, 1 to 2 mL as a ring or local infiltration, without adrenaline) or general anaesthetic in children.
• Frenulotomy technique: make a transverse incision across the frenulum at the point of maximum tension. Close it longitudinally (Heineke-Mikulicz type) with 4-0 or 5-0 absorbable sutures (fast absorbing polyglactin, or chromic catgut), for a lengthening. The procedure takes 10 to 15 minutes. Control bleeding by diathermy or suturing of the frenular artery.
• Frenulotomy complications: bleeding, infection, recurrence (less than 5 percent), and scarring or retraction deformity.
• Postoperative care: wound care with saline, petrolatum or antibiotic ointment, gentle stretching, and abstinence from sexual activity for 4 to 6 weeks.
• Frenuloplasty: a variation (similar closure, Y-V plasty) in more extensive cases, or when frenulotomy alone fails.
• Circumcision: when there is coexistent phimosis, balanitis xerotica obliterans, recurrent balanoposthitis, or if preferred by the patient. Frenulectomy may be added.
• Acute frenular tear with bleeding: apply direct pressure for 10 to 15 minutes, with a topical haemostatic or silver nitrate. Suture or use diathermy for persistent bleeding. Use antibiotic ointment. Antibiotics are not needed unless infected.
• After a frenular tear, abstain from intercourse until healed (about 2 to 4 weeks). Consider elective frenulotomy to prevent recurrence.
• Follow up: review at 2 to 4 weeks and 3 months for healing and function. Counsel on gentle intercourse and lubrication.
• Prognosis: excellent. Sexual function is typically normal after treatment.