Factsheet for health professionals on Lymphogranuloma Venereum

Disclaimer: The information contained in this factsheet is intended for the purpose of general information and should not substitute individual expert advice or judgement of healthcare professionals.

Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by Chlamydia trachomatis, genovars L1–L3. In Europe, the infection occurs predominantly among men who have sex with men, particularly those living with HIV or with additional risk factors for bacterial sexually transmitted infections. It typically presents with a small, painless ulcer at the site of inoculation, followed by tender inguinal lymphadenopathy or proctocolitis. If left untreated, LGV may progress to chronic complications including fibrosis, strictures, and genital lymphatic obstruction.

Case definition

Lymphogranuloma venereum (LGV) is notifiable in the European Union (EU) and European Economic Area (EEA). Member States report confirmed LGV cases to the European Centre for Disease Prevention and Control (ECDC) on an annual basis according to the case definition established in Commission Implementing Regulation (EU) 2026/2097.  If it is not possible to use the EU 2026 case definition, prior versions of the EU case definition or national case definitions may be accepted1.  

The EU 2026 case definition is as follows:

Chlamydial Infection

Clinical criteria:

At least one of the following five:

  1. Urethritis,
  2. Genital ulcer,
  3. Inguinal lymphadenopathy,
  4. Cervicitis,
  5. Proctitis/Proctocolitis.

 Laboratory criteria: 

At least one of the following two:

  1. Detection of Chlamydia trachomatis nucleic acid in a clinical specimen. 

  2. Isolation of Chlamydia trachomatis from a clinical specimen.

    AND

  3. Identification of a Chlamydia trachomatis strain.

Epidemiological criteria:

An epidemiological link by human-to-human transmission (sexual contact or vertical transmission).

Case classification*:

  • Possible case: NA,
  • Probable case: any person meeting the clinical criteria with an epidemiological link,
  • Confirmed case: any person meeting the laboratory criteria.

The pathogen 

Chlamydia trachomatis is a Gram-negative obligate intracellular bacterium that only infects humans [1]. 

Chlamydia trachomatis has a unique biphasic developmental cycle, alternating between an infectious elementary body (EB) and a replicative reticulate body (RB) stage [1-3]. Infection begins when EBs attach to and enter epithelial cells of the urogenital tract, rectum or conjunctiva. Inside the host cell, EBs transform into RBs, which are metabolically active and replicate using host cell resources [1,3] [1,3]. As replication progresses, RBs convert back into EBs, which are released to infect neighbouring cells and continue transmission [3]. Under certain conditions, the bacterium can enter a persistent, non-replicative state that may contribute to prolonged infection before resuming its normal developmental cycle [3,4].

C. trachomatis is classified into three groups of genovars with distinct clinical manifestations [2,4-6]:

  • Genovars A–C cause trachoma, an ocular infection. 
    • Genovars D–K are responsible for most sexually transmitted chlamydia infections. 
    • Genovars L1–L3 cause lymphogranuloma venereum (LGV), an invasive infection affecting the genital and anorectal tract.

The LGV genovars (L1–L3) are uniquely adapted for deep tissue invasion. Unlike the urogenital genovars, which remain confined to superficial mucosal epithelium, LGV strains can penetrate the submucosa, infect phagocytes and spread into regional lymph nodes [2,4,7,8].

The LGV genovars of C. trachomatis exemplify a highly adapted intracellular pathogen, displaying genetic signatures of pathoadaptation in virulence-associated genes that may contribute to their enhanced invasiveness, tissue tropism, and distinctive clinical manifestations compared with non-LGV strains [9].

Clinical features and sequelae 

LGV most commonly presents as an anorectal infection but is also sometimes asymptomatic (estimated at 25%) [10]. Genital and oropharyngeal infections are uncommon [11].

LGV infection is characterised by proctitis and anorectal syndrome, which can involve symptoms including severe rectal pain, bleeding, discharge, tenesmus, and constipation [4,5,9]. On examination or anoscopy, ulceration, mucopurulent exudate and mass-like inflammatory lesions may be observed. LGV proctitis can mimic inflammatory bowel diseases like Crohn’s disease and is associated with more severe complaints when compared to proctitis caused by other C. trachomatis genovars [5,12].

Classically, LGV disease course is characterised by three distinct stages. First, a small painless ulcer develops at the site of infection before other symptoms occur, but this can resolve unnoticed [5]. The secondary stage is characterised by systemic manifestations, such as fever, malaise and arthralgia, alongside inguinal or femoral lymphadenopathy. Untreated, LGV infections can progress to a chronic tertiary stage months or years after initial infection [4]. 

Although uncommon, LGV infection in females may also affect the vagina, cervix and urethra, with the possibility of infection spreading to deeper pelvic nodes, causing lower abdominal, pelvic or back pain [11].

Complications of untreated infection include chronic proctocolitis, rectal strictures, fistulas, and lymphatic obstruction [11].

Epidemiology 

LGV is endemic in some low- and middle-income countries, including countries in Africa, India, Southeast Asia, Latin America and the Caribbean, although epidemiological data are limited in many settings [4,13]. LGV became established within interconnected sexual networks of gay, bisexual and other men who have sex with men across Europe following an outbreak in the Netherlands in 2003 and is now considered endemic in several European countries [10,11]. L2b ompA-subvariant is the predominant strain among European gay, bisexual and other men who have sex with men [9,11,14]. Molecular typing studies suggest a largely clonal epidemic, and retrospective analyses have identified closely related L2b strains specimens collected from gay, bisexual and other men who have sex with men in the United States during the 1980s, supporting the hypothesis of international dissemination through interconnected sexual networks [11,14,15]. 

Epidemiological trends described in the EU/EEA are limited to countries with established LGV surveillance systems and access to molecular diagnostic testing. Among the 18 countries reporting consistently between 2015 and 2024, LGV cases more than doubled between 2015 and 2019, declined during the COVID-19 pandemic, and increased from 2022. The total number of cases increased over 250% overall from 2015 to 2024 [16]. The majority of LGV infections in the EU/EEA are reported in men (98% in 2024) and in individuals aged 25-44 years (67% in 2024) [16]. Heterosexual transmission and infections in women are rarely reported [10,11]. 

While LGV was initially concentrated among gay, bisexual and other men who have sex with men  living with HIV, the proportion of cases diagnosed among HIV-negative individuals in this group has increased steadily over time. In 2024, 35% of cases reporting HIV status (31% of all reported cases) were in people who were HIV positive [16]. 

Enhanced screening strategies have likely contributed to increased case detection. The introduction of routine rectal chlamydia testing among gay, bisexual and other men who have sex with men and reflex LGV testing of rectal C. trachomatis positive samples in countries such as the Netherlands and Belgium led to increased identification of infections among HIV-negative individuals in this group . This suggests that part of the observed increase in notifications reflects improved ascertainment rather than a true increase in transmission alone [17,18].

For updated epidemiological data and figures, please see ECDC’s most recent Annual Epidemiological Report.

Transmission 

Transmission of C. trachomatis LGV genovars occurs primarily through direct mucosal contact with infected lesions, ulcers, or other areas where the bacteria are present [4]. This can include anal, oral, urethral, or vaginal contact. People who are asymptomatic are able to transmit the infection [11]. 

Among gay, bisexual and other men who have sex with men, LGV infection is mostly transmitted through condomless anal intercourse [2] but other routes of infection, such as ano-oral (e.g. oral sex after anal intercourse or rimming), are also recognised as potential routes of transmission [10]. Sexual practices such as fisting, sharing sex toys and enema equipment can also facilitate transmission [11,19]. 

Diagnostics  

Nucleic acid amplification tests (NAATs) are the recommended diagnostic method for C. trachomatis due to their high sensitivity, specificity, and rapid results. They detect C. trachomatis DNA directly from clinical specimens.

Commercially available NAATs may detect chlamydia infection but often do not discriminate between LGV and non-LGV genovars. An LGV diagnosis will require the detection of DNA that is LGV genovar-specific, which is important for both surveillance and clinical management [11,20].

A two-step approach is commonly used for LGV detection [10,11]:

  1. A CE-marked NAAT validated for rectal and pharyngeal samples is applied to detect C. trachomatis.

  2. Given a positive C. trachomatis NAAT result, LGV testing is recommended for all gbMSM and other persons reporting receptive anal intercourse, regardless of symptoms. This sample should be tested with an LGV-specific NAAT.

Suitable specimens include anal swabs (self- or clinician-collected), rectal biopsies via anoscopy or rectoscopy, swabs of ulcer exudate from primary anogenital lesions, and lymph node aspirates. Pharyngeal and urogenital specimens may be used when LGV is strongly suspected based on clinical or epidemiological context [11,20]. 

Alternative methods considered when LGV-specific NAATs are unavailable [11,20]:

  • C. trachomatis-specific serology may support presumptive LGV diagnosis in symptomatic individuals with high antibody titres, though interpretation is limited by lack of standardisation, suboptimal accuracy, and the challenge of distinguishing past from current infection.

  • Detection of rectal polymorphonuclear leukocytes may suggest LGV proctitis but has limited specificity.

  • Culture-based isolation is possible but resource-intensive and less sensitive

Case management and treatment  

Antibiotic therapy is recommended for individuals with LGV who are symptomatic and asymptomatic  as well as their sexual contacts in order to treat infection, prevent complications and reduce onward transmission [11].

The European guideline on the management of LGV infections indicates [11]:

  • first-line treatment: 100 mg doxycycline orally, twice daily for 21 days.

Alternative regimens such as azithromycin (single or multiple doses), or shorter doxycycline courses (7–14 days) have been proposed but are not currently recommended as first-line due to limited supporting evidence [11]. A test of cure is not needed if the full 21-day doxycycline course is completed but is recommended if alternative regimens are used. For further details on alternative regimens and patient management, consult the European clinical guidelines on the management of LGV [11].

Prompt diagnosis and treatment are important to prevent complications and onward transmission [20]. Individuals diagnosed with LGV infection should be informed that it is an STI capable of invading connective tissues and regional lymph nodes [11]. If left untreated, LGV can lead to serious and permanent complications [4]. Individuals diagnosed with LGV should receive indications on treatment administration and be advised to abstain from sexual contact until treatment is completed, and symptoms have resolved. Partner notification should be initiated at diagnosis. Sexual contacts from the past three months of individuals with LGV should be tested from all exposed anatomical sites for C. trachomatis/LGV and offered empiric first-line treatment until LGV is excluded in the patient [11]. 

Symptoms of anorectal LGV typically resolve within 1–2 weeks of initiating antibiotics but inguinal LGV may persist for several weeks and requires follow-up [11]. 

Patients should also receive individual counselling on STI prevention and barrier protection. Testing for other STIs is recommended before starting therapy and at a follow-up visit three months after diagnosis, including testing for syphilis, gonorrhoea, HIV, hepatitis B and hepatitis C. Hepatitis A and B vaccination may also be offered to gay, bisexual and other men who have sex with men [11]. Individuals in this group who are HIV-negative should be informed about the availability and benefits of PrEP, while individuals who are HIV-positive should be advised of the increased risk of hepatitis C associated with unprotected sex, the use of specific psychoactive substances to enhance sexual experiences (‘chemsex’), and sexual practices that could cause injury to the anogenital mucosa (e.g. abrasions or tears). Safe use of enema equipment should be discussed, and referral to substance use services offered when appropriate [11]. 

Prevention

Prevention of all sexually transmitted infections comprises primary prevention, which aims to reduce the risk of acquiring infections, and secondary prevention, which focuses on early detection and treatment to prevent complications and further transmission. 

A key aspect of both primary and secondary prevention of STIs is comprehensive sex education in schools and provision of sexual health information by healthcare providers. This includes knowledge of safe sexual practices, facilitating access to barrier protection and testing services, as well as integrating STI prevention into routine care pathways wherever feasible [21].

A large proportion of STIs are asymptomatic and natural immunity is short-lived, meaning individuals are often unaware of their infectious status, can unknowingly transmit the infection and easily become (re-)infected. 

Primary prevention: reducing risk of STI acquisition

Primary prevention strategies aim to reduce the likelihood of infection during sexual contact. Key measures include:

  • Promotion and provision of barrier protection: Consistent and correct use of condoms, internal condoms and dental dams significantly lowers transmission risk. Access to these should be promoted. 

  • Sexual health education and counselling: Counselling should be tailored to individual needs to support informed decision-making and safer sexual practices. This may include discussion of factors associated with increased STI risk, including multiple or concurrent sexual relationships, mixing across sexual networks and engaging in activities that increase susceptibility to transmission.

  • Risk reduction during symptomatic periods: In the presence of lesions or symptoms including ulcers, discharge, and rashes, individuals should be advised to avoid sexual contact or use appropriate protective measures until symptoms are managed as these are associated with higher infectiousness.

  • Awareness of reinfection and ongoing prevention needs: Since most STIs do not confer lasting immunity after infection, individuals should be aware of the risk of re-infection and encouraged to maintain preventive behaviour post-treatment.

Secondary prevention: early detection and treatment

Secondary prevention aims to shorten the infectious period and prevent complications. Key actions include:

  • Timely healthcare-seeking: Early recognition of symptoms and prompt access to testing and treatment are important. Accessible and integrated services including free or low cost, on demand testing is recommended.

  • Testing: Regular testing in populations at increased risk of infection according to evidence-based national or international guidelines is recommended, as well as provider-initiated testing based on sexual history and assessed risk facilitates early detection. 

  • Effective treatment: Completed course of evidence-based regimens reduces individual morbidity, risk of complications, and community transmission.

  • Partner notification and management: Contact tracing and partner management approaches are useful to prevent reinfection and interrupt transmission chains.

Screening 

Targeted testing strategies are generally recommended for populations at increased risk, including gay, bisexual and other men who have sex with men and users of HIV PrEP [7]. 

National strategy

ECDC recommends that EU/EEA countries maintain a comprehensive national strategy or action plan for the control of STIs, including [19]:

  • access to primary prevention interventions for individuals and groups at increased risk of acquiring the infection, such as gay, bisexual and other men who have sex with men who may have unprotected sex or who have multiple partners,
  • implementation of evidence-based case management guidelines for each setting in which LGV may be diagnosed,
  • robust surveillance of diagnosed infections, implemented to collect epidemiological data on trends, detect outbreaks, characterise cases, and identify risk factors,
  • a plan for monitoring and evaluation of the national strategy’s effectiveness.

The increasing proportions of LGV cases among gay, bisexual and other men who have sex with men who are HIV-negative largely reflects the impact of changes in clinical guidelines and the more frequent testing of individuals in this group who use PrEP for HIV [17,20]. At the same time, it may also reflect ongoing transmission within this population group. The shift in epidemiological trends highlights the importance of adapting public health strategies to effectively control and monitor LGV outbreaks [19].

Advice to travelers

Travellers should be advised to use protection when having sex with new partners during travel. They should pack reliable barrier protection and seek testing if they develop symptoms or if sexual activity during travel posed an increased risk for LGV infection.

References

  1. Witkin SS, Minis E, Athanasiou A, Leizer J, Linhares IM. Chlamydia trachomatis: the persistent pathogen. Clinical and Vaccine Immunology. 2017;24(10):e00203-17. 
  2. Holmes KK, Sparling FP, Stamm WE, Piot P, Stamm WE. Sexually Transmitted Diseases. New York, USA: McGraw-Hill Professional Publishing; 2008.
  3. Stelzner K, Vollmuth N, Rudel T. Intracellular lifestyle of Chlamydia trachomatis and host–pathogen interactions. Nature Reviews Microbiology. 2023 2023/07/01;21(7):448-62. Available at: https://doi.org/10.1038/s41579-023-00860-y
  4. Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 9th ed. Philadelphia: Elsevier; 2020.
  5. Black CM. Chlamydial infection : a clinical and public health perspective. Basel: Karger; 2013.
  6. Hocking JS, Geisler WM, Kong FYS. Update on the Epidemiology, Screening, and Management of Chlamydia trachomatis Infection. Infectious Disease Clinics of North America. 2023 2023/06/01/;37(2):267-88. Available at: https://www.sciencedirect.com/science/article/pii/S089155202300017X
  7. Manning C, O’Neill C, Clarke IN, Rebec M, Cliff PR, Marsh P. High-resolution genotyping of Lymphogranuloma Venereum (LGV) strains of Chlamydia trachomatis in London using multi-locus VNTR analysis-ompA genotyping (MLVA-ompA). PLoS One. 2021;16(7):e0254233. 
  8. Smith EP, Valdivia RH. Chlamydia trachomatis: a model for intracellular bacterial parasitism. Journal of Bacteriology. 2025;207(3):e00361-24. 
  9. Borges V, Gomes JP. Deep comparative genomics among Chlamydia trachomatis lymphogranuloma venereum isolates highlights genes potentially involved in pathoadaptation. Infection, Genetics and Evolution. 2015 2015/06/01/;32:74-88. Available at: https://www.sciencedirect.com/science/article/pii/S1567134815000696
  10. De Vrieze NHN, De Vries HJC. Lymphogranuloma venereum among men who have sex with men. An epidemiological and clinical review. Expert review of anti-infective therapy. 2014;12(6):697-704. 
  11. De Vries H, De Barbeyrac B, De Vrieze N, Viset J, White J, Vall‐Mayans M, et al. 2019 European guideline on the management of lymphogranuloma venereum. Journal of the European Academy of Dermatology & Venereology. 2019;33(10).
  12. De Vries H, Nori A, Kiellberg Larsen H, Kreuter A, Padovese V, Pallawela S, et al. 2021 European Guideline on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens. Journal of the European Academy of Dermatology and Venereology. 2021;35(7):1434-43. 
  13. de Vries HJC. Lymphogranuloma venereum, an invasive and destructive sexually transmitted infection with many faces. Clinics in Dermatology. 2026 2026/01/01/;44(1):29-35. Available at: https://www.sciencedirect.com/science/article/pii/S0738081X2500224X
  14. Harris SR, Clarke IN, Seth-Smith HM, Solomon AW, Cutcliffe LT, Marsh P, et al. Whole-genome analysis of diverse Chlamydia trachomatis strains identifies phylogenetic relationships masked by current clinical typing. Nature genetics. 2012;44(4):413-9. 
  15. Spaargaren J, Fennema HS, Morré SA, De Vries HJ, Coutinho RA. New lymphogranuloma venereum Chlamydia trachomatis variant, Amsterdam. Emerging infectious diseases. 2005;11(7):1090. 
  16. European Centre for Disease Prevention and Control. Lymphogranuloma venereum. In: ECDC. Annual epidemiological report for 2024. Stockholm: ECDC; 2026. 
  17. De Baetselier I, Tsoumanis A, Florence E, Van den Berghe W, Crucitti T, Van den Bossche D, et al. Did pre-exposure prophylaxis roll-out influence the epidemic of rectal lymphogranuloma venereum in Belgium? Results from the national surveillance system. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2021;86(1):e1-e5. 
  18. van Aar F, Kroone MM, de Vries HJ, Götz HM, van Benthem BH. Increasing trends of lymphogranuloma venereum among HIV-negative and asymptomatic men who have sex with men, the Netherlands, 2011 to 2017. Eurosurveillance. 2020;25(14):1900377. 
  19. European Centre for Disease Prevention and Control. Lymphogranuloma venereum. In: ECDC. Annual epidemiological report for 2023. Stockholm: ECDC; 2025. . 
  20. World Health Organisation (WHO). Laboratory and point-of-care diagnostic testing for sexually transmitted infections, including HIV. Geneva: World Health Organization; 2023. 
  21. European Centre for Disease Prevention and Control. Technical Report: Technologies, strategies and approaches for testing populations at risk of sexually transmitted infections in the EU/EEA. Stockholm: ECDC; 2021. 
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