Synopsis
Distinguish invasive lymphogranuloma venereum from chancroid and other genital-ulcer syndromes, obtain specialist testing, and apply pathogen-specific regimens, follow-up and partner lookbacks.
- LGV is invasive infection with C. trachomatis L1–L3: transient ulcer may be missed, followed by painful nodes or proctocolitis with rectal pain, bleeding, discharge and tenesmus.
- Chancroid causes one or more painful soft genital ulcers with ragged undermined edges and tender regional lymphadenitis; it is rare in the UK and usually linked to travel or an outbreak.
- Test LGV with chlamydia NAAT from the symptomatic rectal, ulcer or node site followed by LGV genotyping; a routine negative genital sample does not exclude rectal disease.
Key red flags
Severe anorectal pain, bleeding, tenesmus, fever or abdominal tenderness requires urgent assessment for LGV proctocolitis and inflammatory or surgical mimics.
A fluctuant inguinal bubo can rupture and form a sinus; arrange aspiration or specialist drainage while continuing effective antibiotics.
Neurological, ocular or cardiovascular features require syphilis assessment and cannot be attributed to a local ulcer syndrome.
Pregnancy changes prolonged tetracycline and fluoroquinolone choices and requires specialist infection and maternity advice.
Persistent ulceration after therapy raises herpes, syphilis, mpox, malignancy, resistant H. ducreyi or an incorrect diagnosis.
Severe bleeding, abdominal distension, obstruction, fistula, peritonism or sepsis requires urgent specialist and surgical assessment.
Investigation priorities
Detect C. trachomatis at the affected rectal, ulcer or nodal site and identify invasive L genovars.
Management branches
A patient has painful genital ulceration, inguinal nodes, proctitis or an epidemiological link to LGV or chancroid.
- Record exposure sites, timing, travel, outbreak contact, pain, rectal bleeding, bowel change, systemic symptoms, pregnancy and prior antibiotics.
- Examine skin, oral and genital sites, rectum when appropriate, and inguinal nodes, looking for fluctuance, obstruction and another acute abdomen.