Lymphogranuloma venereum (LGV)

BASHH LGV 2013. Last updated: Dec 2013.

Article Last Updated:28/03/2026

Aetiology

LGV is an invasive STI caused by Chlamydia trachomatis serovars L1-L3, which causes more severe inflammation than the non-LGV serovars (A–K), covered in the Chlamydia article.

Clinical Features

Most UK cases are among MSM involved in dense sexual networks/party scene, not linked to LGV-endemic countries

There are 2 main presentations:

Classic inguinal syndrome (heterosexual presentation)

Classic 3-stage progression:

Primary stage: small, painless genital papule / ulcer
- Often unnoticed and self-resolving
- Often found on coronal sulcus of men and posterior vaginal wall, fourchette, vulva or cervix of women
Secondary stage (2-6 weeks later): painful, unilateral inguinal and/or femoral lymphadenopathy
- Pathognomonic (only present in 15-20% cases): “groove sign” – visible depression between enlarged inguinal and femoral lymph nodes, caused by the inguinal ligament separating the two groups
- Lymphadenopathy can progress into periadenitis and bubo formation, buboes may ulcerate and discharge pus, creating chronic fistulae
Tertiary stage (from chronic inflammation and if untreated)
- Proctocolitis mimicking Crohn’s disease
- Scarring of the vulva
- Genital lymphoedema (elephantiasis) with persistent suppuration and pyoderma

Anorectal syndrome (MSM presentation)

Primary manifestation: haemorrhagic proctitis

Rectal pain
Anorectal bleeding
Mucoid and/or haemopurulent rectal discharge
Tenesmus
Constipatoin
Systemic symptoms (e.g. fever and malaise)

LGV should be suspected in the following patient (exam-rule):

MSM + proctitis
Painless genital ulcer + painful inguinal lymphadenopathy (unlike in syphilis; there is painless ulcer and painless lymphadenopathy)

Investigation and Diagnosis

Sample collection:

Ulcer base exudate or from rectal mucosa
Aspiration of lymph node or bubo
Rectal and pharyngeal swabs from MSM and women exposed at those sites
Urethral swab or first-catch urine specimen when urethritis and/or inguinal lymphadenopathy is present

Tests:

NAAT

1st line test:

Step 1: test for Chlamydia trachomatis DNA
Step 2: typing for LGV-specific DNA

Rectal swab microscopy

Presence of polymorphonuclear leukocytes is predictive of LGV proctitis

Esp. in HIV +ve MSM

Other tests

Serology cannot necessarily distinguish past from current LGV infection and is only available in specialised laboratories
Culture is rarely available and labour-intensive

Management

Similar to those described in the Chlamydia article:

1st line: doxycycline for 21 days
2nd line: azithromycin or erythromycin

Reference

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