Frenulum breve - no reason for circumcision


Frenulum Breve - no reason for circumcision


The Guardian


Frenulum breve affects around 5% of uncircumcised men - and can lead to extremely painful cuts and tears in the foreskin. But information about it is hard to come by, as Jonathan Cope found out

Tell someone you've cut your frenulum and the chances are you'll get a blank look. But if you mention - to a man at least - that you've snapped your banjo string, he'll wince in sympathy. It's probably the most sensitive part of the male anatomy: the ridge of skin beneath the head of the penis, joining it to the foreskin. I've snapped mine twice, the first time during sex seven years ago, when I was 22. It stung, but healed within a week, and I thought nothing more of it - until last summer, when I was washing my penis in the shower and felt a painful twang. On close inspection, there was a barely visible cut on my frenulum. This time it did not heal, and after a week's abstention from sex, my girlfriend twigged.

Reluctantly, I spilled the beans, and we abstained for another couple of weeks but when we tried again my "string" still felt like someone had been picking out Duelling Banjos on it. Like a paper cut, the size of the wound belied the pain it caused. First we turned to NHS Direct for advice, but the creepy adviser's suggestion that we were to blame for having too much sex was unhelpful, upsetting and, as I was to find, nothing to do with the problem.

So I talked to male friends. One or two had suffered and suggested that it would heal, but I didn't like the idea of an indefinite wait. I tried salty baths, Vaseline, Savlon, even Sudacreme - a cream for healing nappy rash - but it didn't heal me. As ever, the internet provided conflicting information, and worryingly, a couple of sites mentioned full circumcision under general anaesthetic and an overnight hospital stay. This was backed up by a nurse I spoke to at Guy's hospital in London; I didn't like the sound of it at all. I rather like my foreskin.

Two months on, confused and increasingly concerned, I visited my local genito-urinary clinic. The consultant suggested either a herpes sore (I really didn't think so) or a tear due to a short frenulum - "frenulum breve" - literally, a "little bowstring'. This, he explained, restricts movement of the foreskin over the head of the penis, leading to soreness, bruising and occasionally a small but painful tear. Apparently it is common, affecting perhaps 5% of uncircumcised men, mostly aged 17 to 30. So why had I never heard of it?

The answer was simple - there is little in the way of published medical research, and people don't talk about it. In 1958, a certain Professor Grewel suggested in the Folia Psychiatrica Neerlandica that the "manifest neglect" of frenulum breve in medical literature is due to a combination of the castration complex among physicians, prudery, and plain masculine pride preventing men from reporting penis problems - as he notes: "When this organ is menaced, fear and anxiety arise." However, my search for the condition using the huge Medline internet database drew a blank.

The GU consultant thought, as I feared, that I might benefit from surgery - not circumcision, thankfully, but something called frenuloplasty. It is difficult to describe in words what this involves, so he drew me a sketch.

The frenulum is cut vertically and the two tiny flaps of skin that this creates are sewn into the foreskin with a couple of stitches. These dissolve in a fortnight, and after a couple of weeks most men have fully recovered and are able to resume sexual activity. It may not sound like fun, but it is preferable to the method practised by the Luo tribe of East Africa, which involves the incisors of the male soldier ant.

After a couple more weeks with no improvement, I decided to leapfrog the potential 15-month waiting list and get my privates checked privately. Gordon Muir, the urologist I visited at King's College Hospital, took a glance at my cut and was "80%" sure that frenuloplasty could help. "You've got a design fault," he explained. "The problem is that, even if your cut heals naturally, you'll be left with scar tissue - thicker but more brittle skin which is prone to splitting again.

"Because we're all different, there's no clear way of knowing just what constitutes a problem frenulum, but as a rule of thumb, it's more likely to cause problems or tear if it automatically pulls the foreskin forward over the head of the penis when you have an erection. The operation is far quicker and less traumatic than full circumcision. We do it with a local anaesthetic as an outpatient procedure and you can go back to work as soon as it's done - unless you're a professional sportsman." I assured him that I was merely a gifted amateur.

"Does it leave a scar?" I asked. "Will it show?" "It depends how closely you look. And if you're still worried," he whispered conspiratorially, "don't be - I've had it done myself, and it was filmed by a group of medical students to boot."

Apparently, many men unaware of frenuloplasty seek full circumcision to cure the problem and are relieved to find that they can in fact keep their foreskins. In a small minority of cases, though, circumcision may be required. Despite Muir's assurances, I was still worried and waited in vain for some natural improvement. Finally, in January this year, about six months after the cut first appeared, I decided to bite the bullet.

The operation was over in 10 minutes - painless apart from the local anaesthetic injection just below the head of the penis. Far worse were the ghastly Y-fronts I had to wear to keep a small gauze dressing in place afterwards. Determined to test Muir's theory, I had a cup of tea at the hospital and went straight back to work (ironically, a meeting at the Department of Health), mentally grimacing at the thought of what I had done, but physically fine.

Over the next month, painful erections were a bit of a nuisance, and I felt a bit low - even emasculated. But when the stitches were removed, I had gone from short bowstring to fit as a fiddle. Daily application of E45 keeps the tiny operation scar supple - it's the lanolin, apparently - and after six months of painful sex followed by a month of none at all, the relief is immeasurable.


The Star

Monday, July 01, 2002

Penile Problems - Frenulum Breve

By Contents Editor - Christina Chew

Penile Problems

The frenulum is like the joining ridge under the tongue. Underneath the glans of the penis there is a small sheet of skin which joins the glans to the foreskin. This is known as the frenulum. If the frenulum is too short on the erect penis, it causes the foreskin to slide forward. When the foreskin is tugged back the tethering effect of this "bridle" causes pain. During intercourse, this can happen and as a result the tight frenulum will often rip and bleed.

There are degrees of brevity. When erect, minor degrees allow the foreskin to retract behind the glans. This causes few problems apart from tension during sexual intercourse which results in a bruised feeling afterwards.

Some men are born without a frenulum. Sometimes the frenulum spreads out like the roots of a tree. Quite often, the frenulum forms one prominent ridge. This ridge runs from the foremost point of the shaft in the cleft between the two cloves under the glans, running back along the shaft and the inner foreskin. When erect, a healthy frenulum allows the foreskin to retract freely. The frenulum can be of any thickness, independent of the length.

What are the effects of frenulum breve?
Problems generally occur during intercourse. Lubrication (e.g. K-y jelly) is necessary during penetration, ejaculation or if their is tightening of the vagina. Pain will result as the foreskin is pulled backwards and strain is put on the frenulum. It is during these times that the frenulum may rip.

The effects of frenulum breve during erection is that when the foreskin is retracted and then let go, the foreskin slides or moves forward again. There is a lot of pulling on the foreskin e.g. during erection the short frenulum pulls the foreskin forward, intercourse, masturbation and ejaculation often causes the foreskin to be pulled backwards.

During masturbation, the erection is manually controlled. Therefore, painful movements can be avoided as the foreskin can be kept in a forward position. Occasionally, pain or ripping are reported during masturbation. However, after masturbation, some men express a feeling of soreness or bruising.

In the case of men who have been circumcised, there is sometimes no foreskin for the tension of the short frenulum to displace. The glans will then bend downwards during erection and as a result of the direct strain, the frenulum will rip.

What are the degrees of Brevity?
There are various degrees of brevity. Frenulum breve is rather mysterious and difficult to understand. The same degree of visible brevity can have different effects depending on where the nerves are present (the area behind the glans and underneath the penis has a good supply of nerves).

  • Short degrees
    The frenulum can be so short that there is actually no frenulum. The foreskin may be attached to the glans or even directly underneath the urinary opening of the glans. If some movement is possible, the foreskin will always slide forward and recover the glans. The effects of these short degrees either hinder penetration or cause pain and rip when attempting to penetrate.

  • Less tight degrees
    Part of the foreskin can be retracted behind the glans and penetration can be carried out. However, this is more likely to cause pain or ripping during ejaculation. Soreness or feelings of bruising may also result. It has been reported that with these less tight degrees, ripping may eventually occur after several years of active sex. Therefore, accumulated effects over years may be greater even although the degree of pain is less and partly avoidable.

What happens when the frenulum rips?
Usually ripping of the frenulum is accompanied with pain and bleeding. This is the most common symptom. For young men experiencing their first sexual encounter when the erection tightens to its limit the frenulum can rip. Usually, these men are not aware that they have a problem until this time. Needless to say, not only the man, but both partners are very worried. However, ripping may occur later, not always on the first sexual encounter.

When ripping occurs, it indicates that the foreskin has retracted fully. Healing may result in scarring which is vulnerable and makes the frenulum even tighter. As a result, there will be a subsequent rip and the process continues. A scab or wart ulcer may occur on the frenulum after it rips and this may break off during sexual intercourse.

There are two main types of frenulum. The frenulum may be thick and sturdy. In this case if the frenulum rips, it can rejoin back. In the case of a thin frenulum (has a string of skin like a hem) when it rips tiny flaps of skin may be left behind which then recede into the shaft skin below the glans. With the thin frenulum breve once the 'hem' rips the rest of the frenulum will then rip easily.

With ageing, the skin tightens. A man who has a frenulum which has caused no problem throughout the years may now find that the frenulum can cause tension, sometimes rip and therefore require surgery.

What is the appropriate treatment?
It is important to discuss treatment with the patient. If the frenulum is found to be too short, having been checked before puberty, all that is needed may be a simple incision. Suture marks can then be avoided and stretching problems with the scar. If frenuloplasty is carried out at an early age when the frenulum is thin, generally the remaining tiny hanging flaps of skin will recede into the shaft skin and the glans.

Surgical treatment - Frenuloplasty
Most men who have had surgical treatment for this problem do not realize just how sensitive as well as erotic the area around the frenulum can be. Prior to operation, the frenulum has held the foreskin forward. Any stimulation to the area in the past would have been extremely painful. It is good to note that any pain experienced prior to operation will turn to pleasure after the operation.

The average age for surgical treatment is from 17 to 27 years old. (This was reported by a Urologist in Germany who operates approximately once a month on these cases). This is a very small operation and is usually done as an out-patient.

The frenuloplasty is performed by making a series of small cuts which are z or y shaped (referred to as a z-plasty or y-plasty). When these cuts are stitched together they form a straight line or a row of 5 or 6 horizontal lines which are barely visible. Healing takes place in about two weeks and the area is considered to be fully functional in about 4 weeks. The frenuloplasty is a proficient operation.

It is recommended that the operation be carried out by a Urologist.

General comments

  • Some men may go through their entire life without knowing that they have this problem. Many men do not even know that there is a cure.

  • There is a tendency for the adolescent to forget to wash the area because of the overall impression that the foreskin remains forward.

  • Due to the condition, it is problematic to use a condom due to the annoying pulling.

  • Take note: Any pain experienced prior to operation will turn to pleasure after.

Copyright 2002 Sdn Bhd.

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