What is the treatment for Frenulum breve?

Treatment of Frenulum Breve

For men with frenulum breve (short frenulum), topical steroid therapy with betamethasone 0.05% or clobetasol propionate 0.05% ointment applied twice daily for 4-6 weeks should be the first-line treatment, with frenuloplasty reserved for cases that fail medical management. 1

Initial Medical Management

• Apply topical corticosteroids as first-line therapy before considering surgical intervention 1
• Use betamethasone 0.05% ointment applied to the frenulum twice daily for 4-6 weeks 1
• Alternatively, clobetasol propionate 0.05% ointment once daily for 1-3 months can be used 1
• Instruct patients on proper application technique directly to the tight frenular tissue 1
• If improving but not fully resolved after initial course, continue treatment for an additional 2-4 weeks 1
• For recurrence after successful medical treatment, repeat the topical steroid course for 1-3 months 1

When to Consider Surgical Intervention

Proceed to frenuloplasty only after failure of adequate topical steroid therapy 1

Key Indications for Surgery:

• Persistent symptoms despite 4-6 weeks of topical steroid treatment 1
• Painful erections or significant pain during sexual activity that warrants more urgent intervention 1
• Recurrent frenular tears during intercourse 2, 3
• Mechanical restriction causing erectile dysfunction 1

Surgical Technique: The "Pull and Burn" Method

The "pull and burn" method is the preferred surgical approach as it is suture-free, preserves the frenular artery, and prevents meatal stenosis 3, 4

Procedural Steps:

• Achieve local anesthesia with EMLA cream applied for 15-20 minutes (sufficient in 98.4% of cases) 3
• Identify the point of maximum tension on the frenulum 3
• Cut the frenulum at this point using low-power, high-frequency diathermy 3, 4
• Apply gentle but firm retraction on the glans to create a controlled vertical tear of the frenulum 3
• Seal minor bleeding with diathermy, carefully avoiding the underlying frenular vessels 4
• Do not use sutures unless dealing with a very wide and thick frenulum requiring edge approximation for cosmesis (needed in only 1.6% of cases) 3
• Apply paraffin gauze with antibiotic paste followed by light compression dressing for one day 2

Critical Technical Points:

• Preserve the frenular artery to prevent meatal stenosis and ensure optimal functional outcomes 2, 4
• Avoid injury to the glans penis 2
• Tear the frenulum superficially and vertically, avoiding underlying frenular vessels 4
• Do not use diathermy for the initial division when using scalpel technique 2

Alternative Surgical Approaches

CO2 Laser Frenuloplasty:

• Consists of frenulum vaporization using CO2 laser 5
• Provides good aesthetic results with complete symptom resolution 5
• Reduces risk of residual scarring compared to traditional surgical methods 5

Traditional Frenuloplasty with Sutures:

• Divide frenulum with scalpel without diathermy 2
• Reapproximate with interrupted 4-0 absorbable sutures 2
• Maintain the frenular artery during dissection 2

Special Considerations

Lichen Sclerosus:

• Always rule out lichen sclerosus as an underlying cause, which may require different management 1
• Phimosis or frenular pathology caused by lichen sclerosus may be less responsive to topical steroids 1
• Higher likelihood of requiring surgical intervention for lichen sclerosus-related frenular disease 1
• If circumcision or frenuloplasty is performed, always send tissue for histological examination to exclude penile intraepithelial neoplasia 1

Urgent Situations:

• Men experiencing painful erections or significant pain during sexual activity may warrant expedited treatment or earlier consideration of surgical options 1
• Risk of paraphimosis increases if tight frenulum becomes trapped behind the glans during erection 1

Outcomes and Follow-up

Expected Results with "Pull and Burn" Method:

• No meatal stenosis reported in 228 patients (96.6% follow-up) over 15 years 4
• Excellent functional and cosmetic results in all cases at 3-month follow-up 3
• Only 0.8% required further release of scarred frenulum 3
• No inflammation or meatal stenosis at 3 months 3

Post-operative Care:

• Advise personal hygiene 3
• No local antiseptics or antibiotics required 3
• Regular follow-up at 2-3 months postoperatively 4

Common Pitfalls to Avoid

• Many patients are referred for surgery without an adequate trial of topical steroids - always attempt medical management first 1
• Using sutures unnecessarily increases risk of severing the frenular artery and causing meatal stenosis 3
• Aggressive diathermy can damage the frenular artery and lead to complications 2, 4
• Failure to consider lichen sclerosus as underlying cause, especially if resistant to treatment 1
• Not sending surgical specimens for histological examination 1