Approach

Early stages of disease can be treated effectively with antibiotics. Advanced disease may require surgical evaluation; however, incision, and drainage or surgical excision should be avoided when possible as these procedures may impair lymphatic drainage, lead to formation of sinus tracts, and complicate healing. If confirmatory laboratory tests are not rapidly or readily available, then a patient at risk with a clinical syndrome suspicious LGV warrants empirical treatment.[21]

Patients with primary LGV

Doxycycline is the recommended first-line treatment for early stage of disease. Prolonged antibiotic treatment should not be required for primary LGV. Although one retrospective review in men who have sex with men suggests that 7 to 14 days of doxycycline may be sufficient for rectal LGV, there is not enough evidence to support a duration of treatment shorter than 21 days.[45]

When tetracyclines are contra-indicated (e.g., patients with allergies to tetracyclines or pregnant or lactating women), erythromycin is the treatment of choice.

Azithromycin is also an alternative treatment. Although it has not been confirmed to be effective in clinical trials, the use of azithromycin is generally accepted if a patient is pregnant or lactating, if a patient has an adverse drug reaction to doxycycline or erythromycin, or if poor adherence with medicine is a legitimate concern.[1][30][44] In one trial of 125 patients with LGV proctitis, clinical and microbiological cure rates suggest azithromycin taken once weekly for 3 weeks may be as effective as standard doxycycline.[46]

If disease is still present after 3 weeks of therapy, alternative diagnoses should be ruled out. Prolonging or broadening the spectrum of antibiotics, therefore, may be necessary for other infections or bacterial super-infection.

Patients with secondary LGV

Antibiotics are used to eradicate infection as in the early stages of disease.

Pus is aspirated from bubonuli using a lateral approach through normal skin to prevent rupture and formation of sinus tracts.[1][47]

Incision and drainage or surgical excision of inguinal buboes is avoided where possible as these procedures may impair lymphatic drainage, lead to formation of sinus tracts, and complicate healing.[1][22]

Patients with tertiary LGV

Antibiotics are used to eradicate infection as in the early stages of disease.

Disfiguration of the genitalia associated with esthiomene or elephantiasis may not resolve with antibiotic treatment alone. Plastic surgical reconstruction is considered several months after antibiotic treatment is completed and there is evidence that there has been resolution of active disease.[1][22][47]

Advanced anorectal disease may require surgical evaluation by specialised and experienced teams. Though inflammation greatly improves, rectal strictures do not resolve with antibiotic treatment alone. Indications for surgical intervention include stricture formation, bowel obstruction, rectovaginal fistula and gross destruction of the anal canal, anal sphincter, and perineum.[1][47]

Patients with asymptomatic LGV

A regimen of doxycycline for 7 days has been typically used for asymptomatic rectal infections caused by non-LGV Chlamydia trachomatis; however, European guidelines do not recommend courses shorter than 21 days.[1]

Although there is lack of evidence to support either single- or multi-dose regimens of azithromycin, up to 20% of patients with asymptomatic rectal chlamydial infections remained persistently positive when returning for test of cure after a single dose of azithromycin, compared with 1% to 10% of patients treated with doxycycline.[44]

Patients exposed to LGV

Anyone who may have been exposed by contact, either from unprotected sexual intercourse within 60 days to 3 months of the partner's presentation of symptoms, or by direct contact with an LGV lesion or discharge from a lymph node or the rectum, should be contacted for assessment, counselling, and post-exposure prophylaxis or antibiotic treatment.[1][30]

Early presumptive treatment is indicated in this situation because primary lesions are seldom discovered.

Co-infection with HIV

Patients with HIV and LGV should receive the same treatment regimens as those who are HIV-negative; however, close follow-up is required to ensure resolution is achieved.

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