Short Frenulum (Frenulum Breve): Tearing and Bleeding During Sex, and Frenuloplasty

A sudden, sharp pain under the head of the penis during sex, followed by an unexpected amount of blood. Most men think the band under the penis has snapped and wonder whether the damage will be lasting. Another man has never bled at all, but notices at every erection that the head of the penis is pulled downwards and feels tight underneath.

The frenulum is the thin band of tissue that joins the underside of the head of the penis, from just below the urinary opening, to the inner surface of the foreskin; it is often called the banjo string. When this band is too short or too tight to allow for an erection, the condition is called a short frenulum (frenulum breve). This article covers how it is recognised, its causes, what to do when it tears and bleeds, its link with premature ejaculation, frenuloplasty and the other treatment options.

How is a short frenulum recognised?

The British Association of Urological Surgeons (BAUS) notes that a tight frenulum can cause pain during erection or intercourse and may tear, causing bleeding and discomfort. The signs most often described are:

• The head of the penis being pulled downwards during erection
• A pulling pain on the underside when the foreskin is drawn back or during intercourse
• Small splits in the band and bleeding after intercourse or masturbation

In one surgical series that sent a questionnaire to men after frenuloplasty, 32 of the 48 who replied gave tearing and bleeding as their reason for seeking help and 26 gave pain on intercourse.

Why is the frenulum short?

The shortness can be present from birth. The band is then structurally short, and the problem is usually noticed in adolescence or when sexual activity begins. In Denmark, among 181 boys who had foreskin surgery for medical reasons before the age of 18, the indication in 5% was a short frenulum causing problems during erection. In an adult series reported from Greece, the median age of the patients was 21.4 years.

Shortness can also develop later. Repeated tears leave scar tissue. Lichen sclerosus, a chronic scarring skin disease, can involve the frenulum as well as the foreskin. Recurrent balanitis (inflammation of the head of the penis) and phimosis (a tight foreskin) may also accompany the picture; these topics are covered in separate articles on this site.

Can it occur in circumcised men too?

Yes. Circumcision removes the foreskin, but the part of the frenulum attached to the head of the penis may stay in place and can be short or scarred. In China, of 34 men assessed for premature ejaculation who were all found to have a short frenulum, 8 had previously been circumcised.

In another study from China, which looked back at 160 adult circumcisions, a short frenulum was reported after the operation in 8.75% of the 80 men circumcised by the usual method, and in none of the group in whom the frenulum was specifically positioned. These are retrospective, single-centre data. Other problems remaining after circumcision are covered in a separate article on this site.

What happens if the frenulum tears during sex, and what should be done first?

The tear usually occurs at the tightest point of the band. Information from a UK sexual health organisation states that a frenulum tear can be very painful and can bleed a lot, yet in most cases heals without any treatment. One reason the bleeding looks alarming is that one or two small arteries lie in the bed of the frenulum.

The first steps are simple. Applying gentle, continuous pressure to the bleeding point with a clean cloth or gauze is a general first aid principle; a hospital leaflet from England recommends the same for bleeding after frenulum surgery. Severe bleeding, or bleeding that does not stop, needs an emergency department. The same text advises avoiding all sexual activity, including masturbation, until the wound has healed completely, and seeing a doctor if it does not heal.

Serious infection after a tear is rare; the medical literature describes infection of the penile skin arising in this way in a single case report.

Why does a tear that healed by itself come back?

A tear usually closes with scar tissue. Scar tissue does not stretch as well as healthy tissue, so the healed band can end up shorter and stiffer than before and may tear again at the same spot at the next intercourse. In the Greek series, 43 of the 228 patients followed up (19%) had a history of earlier frenulum injury during intercourse and had scar tissue at the time of surgery. BAUS likewise describes the common feature of frenulum-lengthening techniques as dividing the tight area of scar tissue.

A single small tear can heal without leaving a mark. The same text notes that using a lubricant once the tear has healed may help to prevent another tear. If tears keep recurring, the cause should be assessed without waiting.

Does a short frenulum cause premature ejaculation?

This claim is often made, but the evidence is limited. At a single centre in Italy, a short frenulum was found in 59 of 137 men (43%) presenting with lifelong premature ejaculation, and after removal of the frenulum (frenulectomy) in these men the mean time to ejaculation rose from 1.65 minutes to 4.11 minutes. Mean follow-up was 7.3 months. The study had no comparison group, so the effect of expectation cannot be separated from the true effect of the operation. The series of 34 men from China has the same limitation.

A review of frenuloplasty stresses that the available studies rest on small numbers of participants and that comparative, long-term, high-quality data are lacking. In the ejaculation disorders chapter of the European Association of Urology (EAU) guidelines, frenulum surgery does not appear among the recommended treatments for premature ejaculation. This procedure is therefore carried out for pain and tearing; there is no guideline basis for it purely to prolong the time to ejaculation. The treatment of premature ejaculation is covered in separate articles on this site.

What are the treatment options?

The choice depends on how troublesome the symptoms are, whether scarring is present and the condition of the foreskin.

• Observation: BAUS notes that mild cases may need no specific treatment.
• Treating an underlying skin disease: If lichen sclerosus or balanitis is present, that is dealt with first; treatments such as a steroid cream are for a doctor to decide.
• Frenuloplasty: A procedure that lengthens the band while preserving it.
• Frenulectomy: Dividing the band so that it is released, or removing it.
• Circumcision: According to BAUS, an option instead of frenuloplasty, or afterwards if symptoms do not improve.

In a series of 106 men who had frenuloplasty over a 10-year period, the satisfaction score among the 96 patients reached at least 1 year later averaged 8.9 out of 10; 8% had later needed a circumcision. In the other, questionnaire-based series, 23 of 209 patients (11%) had been circumcised after frenuloplasty, although only 23% had answered the questionnaire. These series were uncontrolled. The authors of a small case series state that frenuloplasty alone is not suitable when phimosis is also present.

How is frenuloplasty done, and what are the recovery and the risks?

Frenuloplasty is a short procedure carried out by urologists. As BAUS describes it, the tight skin is divided across and stitched lengthwise, which lengthens the band. It is done under local or general anaesthetic and, according to the review, usually on an outpatient basis. The stitches dissolve by themselves and usually disappear within 2–3 weeks.

According to the BAUS patient information leaflet, swelling and bruising lasting several days are to be expected, the area is kept dry for 24–48 hours, and sexual activity is avoided for up to 4 weeks or until the wound has healed completely. The risks listed in the same leaflet are as follows:

• Swelling that may last 7–14 days: between 1 in 2 and 1 in 10 patients
• Reduced sensation in the head of the penis, bleeding that may need a hospital visit, and failure of symptoms to improve with a need for circumcision: each between 1 in 10 and 1 in 50 patients
• Infection needing antibiotics, tenderness of the scar and dissatisfaction with the appearance: each between 1 in 50 and 1 in 250 patients

When should you see a doctor?

Assessment is needed in these situations:

• Severe bleeding, or bleeding that does not stop despite pressure: go to an emergency department
• A cracking sound during intercourse, sudden loss of the erection, and rapidly developing swelling and bruising: this may be a penile fracture, so go to an emergency department or call 112 without delay. Penile fracture is covered in a separate article on this site.
• Recurrent tears or bleeding
• The head of the penis being pulled downwards during erection, or a pulling pain that makes intercourse difficult
• A wound that does not heal: the medical literature includes a report of a sore thought to be a frenulum tear that turned out to be syphilis
• Spreading redness, swelling, discharge or fever
• Whitish, hardened patches on the foreskin, or tightness that is new

A frenulum tear usually heals by itself, whereas recurrent tears, pain and tightness call for assessment of the underlying shortness. Treatment is planned according to the symptoms and the state of the tissue. Assoc. Prof. Dr. Zülfü Sertkaya practises urology and andrology in Istanbul; assessment of a short frenulum and frenulum problems is individualised and carried out in confidence.

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