Lymphogranuloma Venereum

Lymphogranuloma venereum (LGV) is caused by the invasive Chlamydia trachomatis serovars L1, L2, and L3, which preferentially infect lymphatic tissue rather than the epithelium the way ordinary genital chlamydia does. It is transmitted through vaginal, anal, or oral sexual contact. LGV needs a much longer treatment course than uncomplicated chlamydia — 3 weeks rather than 7 days — because of this deeper tissue invasion, and untreated infection can leave permanent structural damage.^[1]

• Suspect LGV specifically in a patient (particularly men who have sex with men) presenting with proctitis symptoms, especially with bloody anal discharge — this is the presentation most likely to be missed as "just" ordinary proctitis or hemorrhoids.
• Can also present with genital ulceration or inguinal lymphadenopathy at the site of inoculation.
• Individuals with genital ulcers from any cause, including LGV, are at increased risk of acquiring and transmitting HIV.

Complications of untreated infection include anorectal fissures, fistulae, and strictures, along with secondary bacterial infection of the affected tissue — these are the consequences of the deeper lymphatic invasion that distinguishes LGV from ordinary chlamydia.

• Receptive anal intercourse, particularly in men who have sex with men.
• A sexual partner with confirmed or suspected LGV.
• Other concurrent STI exposure.

Testing for LGV is typically performed at a reference laboratory and sometimes needs a specific request rather than being part of routine chlamydia testing. If a rectal specimen is positive for chlamydia, test specifically for LGV serovars — in some jurisdictions a positive rectal chlamydia NAAT automatically triggers LGV serovar testing, in others it must be requested explicitly, so know your local laboratory's practice. LGV testing on non-rectal specimens (culture or NAAT) can also be done when suspected, for example with genital lesions; serology is not generally recommended for diagnosis.^[1]

• Eradicate the infection and prevent progression to stricture, fistula, or fissure formation.
• Eradicate infection in sexual partners from the relevant exposure window.
• Resolve proctitis or ulcerative symptoms.

• Refer sexual partners from the 60 days preceding symptom onset (or diagnosis, if the patient was asymptomatic) for testing and empiric treatment.
• Advise abstaining from sexual contact until the patient and treated partner(s) have completed therapy.

Pregnancy and breastfeeding: doxycycline is contraindicated. Erythromycin (not the estolate salt, due to cholestatic hepatitis risk) or azithromycin can be used instead, following the same 3-week case-treatment durations as outlined in Choose Initial Treatment.

• Perform test of cure 3-4 weeks after completing treatment.
• Continue follow-up until chlamydial testing is negative — do not stop at a single negative result if the timing is borderline.
• Monitor clinically for resolution of proctitis symptoms and for development of stricture or fistula, which can occur even after microbiological cure if tissue damage was already established.

1. Confirm the full 3-week course was completed — a partial course is a common reason for apparent failure.
2. Confirm partner treatment and exclude re-exposure.
3. Repeat testing rather than assuming failure from symptoms alone, since post-infectious symptoms can persist even after cure.
4. Refer for surgical assessment if stricture, fistula, or fissure has developed.

• Treating LGV with the standard 7-day chlamydia course instead of the full 3-week LGV course.
• Missing LGV in a patient with proctitis and bloody anal discharge by attributing symptoms to hemorrhoids or ordinary proctitis without testing.
• Not requesting LGV-specific serovar testing on a positive rectal chlamydia result when your laboratory does not do this automatically.
• Using doxycycline in pregnancy or breastfeeding.

How to use this table: Doses are adult doses and require patient-specific confirmation. Test and treat sexual partners from the preceding 60 days. Select any drug name to open its complete Pharmasist Drug Database page.

Tetracyclines — Preferred

3 weeks of treatment — much longer than the 7-day course used for uncomplicated chlamydia.

Macrolides — Alternative

For pregnancy/breastfeeding or when doxycycline cannot be used.

Evidence note: Drug inventory, dosing, adverse effects, and comments reflect standard Canadian practice per current PHAC guidance.^[1]