I advise first reading The Common Delusion which is probably better written and describes my basic motivations.

This was sent to the BMJ in year 1999 : Paper 995692 was probably rather confusing and not up to academic standards; also it was the wrong title. It was refused.

I have now (2014) marked some places Black these seemed particularly clear or good.

See also : The value of routinely monitoring boys for phimosis before puberty and is the BMJ biased

The Importance of Monitoring Boys for Frenulum Breve
by R. Stuart

Abstract
This essay discusses frenulum breve, literally the 'short bridle' of the prepuce. During erection the tethering effect of a short frenulum holds the foreskin in a forward position. Pain, bruising, tension, and soreness are caused by the foreskin being pulled backwards, straining and often ripping the very sensitive frenulum. This essay demonstrates that frenulum breve must be monitored and corrected before puberty.

Keywords: frenulum, phimosis, male, initiation, monitor, prepuce,

Introduction

Diderot commented in 1779 that the frenulum meritted "more attention on behalf of doctors, who until present had not done this" . In 1957 Grewel [1] spoke of "a general or collective repression of the phenomenon." Though he was referring principally to frenular rips, modern medical literature [2,3] (Pienkos, Whelan) confirms that "The existence of a short frenulum is noted in few urological text books." [3]

The effects of frenulum breve are often misunderstood, recent texts[3,8] suggesting it is the ventral curvature in the shaft of the penis with the glans bent downwards which causes pain, While this is a useful concept for diagnosis in the flaccid state it presents a misleading picture of the erectile consequences. Men with this condition do not normally hold their foreskins in the retracted position, and upon release such a curvature is self correcting, supporting the spring action which always returns the foreskin to the forward position, thus they rarely experience any curvature.

The male frenulum takes the form of a short prominent ridge anchored in the "V" shape under the glans which joins the inner blade of the prepuce dorsally to the glans penis. It can develop great diversity in shape, thickness, and tensile strength and it can be so short that it pins the foreskin to the glans directly under the meatus. Depending on its length and nervous structure the frenulum can stimulate considerable pain or pleasure.

Frenulum breve is correctly described as a tether. The medical literature speaks of a "tethering effect" [4,5] which "tends to pin and tie down the foreskin", [6] producing a slanting oblique shape at the opening of the prepuce which makes retraction difficult. [7] It appears the consequences during sexual activity have never been further described. On attempted retraction the tethering effect of frenulum breve returns the foreskin to its forward position, when the foreskin is pulled backwards, this strains at the very sensitive frenulum which will often rip, or cause pain, bruising, tension, or soreness.

It is worth noting that while the animals penis is considerably different from the human penis the effects of "persistent penile frenulum" are very similar. If the frenulum fails to rip in the foetal stage, it causes erection curvature (as there is no foreskin for the short frenulum to pull upon), or it can rip and bleed during intercourse. [9,10] Remarkably, whereas statistical information on the condition among humans is non-existant, statistics on the persistent frenulum among animals are readily available (between 0.5% and 5.7%), [9,11,12] and the condition is monitored as part of the Breeding Soundness Examination. [11]

Methods of Investigation

In 1995 I conducted a series of interviews among an unselected group of over a hundred men and fifty women. The sample was between 18 and 80 yrs. old with an average age of 30, This provided general information, an impression on frequency and valuable insights into a variety of experiences. Women often reported a different perspective - of a man who was always flaccid during intercourse except during ejaculation when it hurt him - and a young man who was obviously unaware of a cure for his condition advising his girl friend to not touch the area.

The increasing potential of the World Wide Web presented a unique opportunity to research these issues among a large and widespread population in the computer literate world, and since 1996 as manager of the first internet site concerned with foreskin problems. Letter exchanges with over 500 people revealed extra-ordinary coicidences - a library contains a sample of the most interesting letters over the first 4 years - two public forums recorded over 200 questions in the last year.

The information and experiences were distilled and recorded on the main html page "Frenulum Breve", [13] - a web of subsidiary files examine treatment, current attitudes and comparison with phimotic ring.

On one added page I collected the results of research through the entire available literature on the frenulum from the Index Medicus between 1920 and 1967 and then from 1966 onwards the MEDLINE and DIMDI data banks. [14] The Internet provided additional information from one quite remarkable booklet on the traditional routine operation as performed by the Luo of East Africa. This describes a variety of methods of cutting the frenulum including the use of the local breed of soldier ant, the Okoko, whose jaws grip and sever the frenulum. [26] Bryk the anthropological expert on the "foreskin complex" was also consulted, an incision of the frenulum was traditionally practised on Tahiti and the Loyalty Islands. [27]

Results

We can define 4 different lengths of frenulum

extra long: some men have a frenulum which is so long that during masturbation they pull on it to acheive orgasm

adequately long: some men it is long enough to allow easy retraction with no feeling of tension

border line: some feel it pulling during intercourse among these some complain of premature ejaculation whereas others feel without this stimulation they would not ejaculate - this could be as much due to length of the frenulum as individual psychology.

frenulum breve: when it is too short it will either rip or cause pain either during or after intercourse - whether it rips or not probably depends more on the thickness of the frenulum than its shortness.

Frenulum breve makes retraction past a given area, uncomfortable or painful or occasionally pleasurable. Youths will generally avoid any pain or difficulty and adapt to a comfortable method of masturbation by keeping the foreskin forward or at least not retracting it too far. Though bruising is often reported after masturbation, when the subject is able to control the position of his own foreskin, pain or ripping are only very occasionally reported. [1,16]

The difficulties with frenulum breve typically become obvious during intercourse due to the involuntary movement of the foreskin. At these times when the foreskin is unable to retract further, it tugs on the frenulum which then often rips or is painful.

Ripping occurs particularlv often during penetration [4.5] and often during ejaculation. Rips are often reported during first intercourse [1,17] and can bleed profusely [1,18] "... causing a moment of great alarm for both participants ... " [17] or "... feelings of shame and self reproach [1] Sometimes these rins heal spontaneously. [7] but thev can also rip and mend in a repeated fashion, [7,19] on occasion rejoining and causing the frenulum to become even shorter. [7]

Frenular rips were reported far more often than a surgical correction, among the 150 men questioned 6 cases of ripping and among 50 women reported 2 more cases - no surgical corrections in the initial sample group. Most cases of ripping had not been reported to a doctor. This implies that the frequency of frenular rips is probably underestimated. It appears that there are many thinner frenulum types which rip successfully with little pain; the tendency to rip, bleed profusely, and rejoin, possibly occurs when the frenulum is thicker. The continual process of ripping and rejoining results in doctors visit and is not common.

Possibly it is the more moderate degrees, the border line cases which cause aches and bruising due to the strain of repeated pulling and stretching, these hinder sexual activity for two or three days afterwards. In addition, frenulum breve is recognised as leading to premature ejaculation [21] though this again may be an uncommon effect, but a primary reason for seeking clinical opinion.

In conclusion, frenulum breve is often combined with a relative or partial phimosis and this can considerably complicate the anatomical and sexual effects.

Discussion

With frenulum breve, as with phimosis, [17,22,23,24] at times the subjects themselves are quite unaware of their condition. The restriction lies hudden underneath the glans and behind theforeskin, which is tethered in a forward position, therefore during erection the subject must endure a certain amount of discomfort, and then turn the erect member sidewards to reveal the nature of the problem - a contortion which Houdini would have been proud of. Men frequently complain of discomfort, tightness or pain, and show little awareness of its cause. The perpetual recovering of the glans commonly results in the impression of a "redundant" overlong prepuce. It is probablv partly due to the elusive anatomical nature of this condition that men "will not dare confront the problem." [21]

A number of the men concerned believe that they are "normal" and adapt their beliefs and behaviour to their anatomical conditions.The subject accepts his condition and has adapted to it since puberty (and probably to some extent since infancy). Feelings of considerable disorientation are understandable Chitale suggests "1) bleeding after sexual intercourse; 2) tear of frenum ... which does not heal easily; 3) ... pain after erection, and 4) all the above conditions cause psychoneurotic problems." [8] There is possibly no other group of problems which could be so easily prevented.

Surgery, when necessary, is usually performed in early adulthood, one study suggests an age range between 19 and 41 years old. [20] Most doctors (possibly excepting those in the US and other countries practising routine circumcision) are aware that circumcision is not an appropriate operation to cure this condition, a frenuloplasty or frenoplasty is usually recommended.

Conclusion

A considerable proportion of the male population suffer from an anatomical impediment which is reported to cause difficulty and trauma by sexual activity. This commonly involves a shock for both partners as the frenulum rips and bleeds during first intercourse. Alternatively a neglected frenulum breve may cause years of repeated ripping and mending, or pain and discomfort, during and after sexual activity, and this may lead to considerable frustration and disturbances in the sexual behaviour, before being operated in adulthood.

Frenulum breve is an important reason why the early monitoring of such conditions which inhibit the full movement of the prepuce be routine practice. Steps should be taken to correct the condition before it starts creating problems, rather than treating it after the problems have arisen. Information on the subject appears desirable to include in the school sexual education curriculum and would add an enlightening chapter to many sexual advice books.

R. Stuart