Primary manifestation of lymphogranuloma venereum infection is painless penile or vulvar inflammation and ulceration at the site of inoculation; often not noticed by the patient.
Secondary stage typically occurs weeks after development of the primary lesion; presents as painful, unilateral, inguinal or femoral lymphadenopathy (often referred to as 'inguinal syndrome').
Proctocolitis has emerged as a more typical presentation in men who have sex with men (particularly those who are HIV-positive).
Chronic inflammation can lead to scarring and fibrosis causing lymphoedema of the genitals, or formation of strictures and fistulae if anorectal involvement.
Identification of Chlamydia trachomatis from the swab of a genital ulcer or aspiration of a bubo is definitive diagnosis.
Doxycycline is the preferred first-line treatment; macrolides are an alternative treatment option (e.g., in pregnant or lactating women, or patients with allergies to tetracyclines).
Large buboes may be aspirated, but incision and drainage or surgical excision of buboes may complicate healing.
Lymphogranuloma venereum (LGV) is a STI caused by Chlamydia trachomatis genovars/serovars L1, L2, or L3 (collectively termed the 'LGV biovar'), which are endemic to the tropics, but now emerging in developed regions. Infection occurs through contact with mucous membranes or abrasions in the skin of the genital region.
History and exam
Key diagnostic factors
- presence of risk factors
- inguinal lymphadenopathy
- non-specific symptoms of proctocolitis
- groove sign of Greenblatt
- genital elephantiasis, saxophone penis, esthiomene
Other diagnostic factors
- fever, malaise, arthralgias
- lower abdominal or lower back pain
- genital or anal ulcer
- non-specific symptoms of bacteraemic spread
- erythema nodosum
- anogenital sinus tracts, strictures, or fistulae
- other STIs
- risky sexual behaviour
- age (20 to 40 years)
- unprotected intercourse in an area endemic for LGV
1st investigations to order
- genital or lymph node specimens for nucleic acid amplification testing (NAAT)
- swab via anoscopy for Gram staining
- fluid or swab for LGV-specific molecular testing
- STI testing
Investigations to consider
- endoscopy with histopathology
- serum for complement fixation
- serum for micro-immunofluorescence (MIF)
- CT of abdomen and pelvis
- MRI of abdomen and pelvis
- fluid or swab for culture
- fluid or swab for genovar typing
asymptomatic adolescent and adult patients who have been exposed to lymphogranuloma venereum (LGV)
all stages of lymphogranuloma venereum (LGV)
Benjamin D. Lorenz, MD
Division of Hospital Medicine
MedStar Georgetown University Hospital
BDL declares that he has no competing interests.
Dr Benjamin D. Lorenz would like to gratefully acknowledge Dr Mettassebia Kanno, a previous contributor to this topic.
MK declares that she has no competing interests.
Cees van Nieuwkoop, MD
Department of General Internal Medicine
Leiden University Medical Centre
CvN declares that he has no competing interests.
David Chelmow, MD
Department of Obstetrics and Gynecology
Virginia Commonwealth University
DC declares that he has no competing interests.
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