LGV: the STI a normal chlamydia test misses

LGV is an STI caused by chlamydia, but by the more aggressive types L1, L2 and L3. A normal chlamydia test sees that it is chlamydia and not which type. That difference counts, because LGV needs a longer course of antibiotics than ordinary chlamydia.

The full name is lymphogranuloma venereum. In the Netherlands it occurs mainly in men who have sex with men.

Below you will find what it is, why the standard test misses the type, and what the Dutch figures over recent years show.

What is LGV?

It is an invasive form of a chlamydia infection. Where ordinary chlamydia stays in the mucous membrane, LGV pushes through into the lymphatic tissue beneath it. That explains why the symptoms can be heavier and why a short course does not suffice.

The pathogen is the same bacterium, Chlamydia trachomatis, just a different serovar.

In the Netherlands, LGV appeared from 2003 onwards in men who have sex with men, at first mainly in men with HIV (van Aar, 2020). That picture has since shifted, and that is exactly why this page exists.

Which symptoms does LGV cause?

With a rectal infection, LGV classically causes a heavy proctitis: severe pain in and around the anus, blood or mucus, and a strong empty urge. The European guideline names LGV explicitly as a cause of proctitis and notes it is increasingly found in HIV-negative men (de Vries, 2021).

Sometimes there are swollen lymph nodes in the groin.

But that reputation no longer quite holds.

Dutch surveillance figures show the share of LGV patients without symptoms rose from 31.4 percent in 2011 to 49.3 percent in 2017 (van Aar, 2020). So roughly half of the cases found notice nothing at all.

Why does a normal chlamydia test miss LGV?

Because a standard PCR shows that Chlamydia trachomatis is present, without distinguishing the ordinary types from the L types. Establishing LGV needs an extra typing step on the same sample. Without it, the result simply reads "chlamydia positive".

There is a second issue. With rectal symptoms the infection is only found if a swab of the anus was taken. A urine test yields nothing here, as we set out in anal chlamydia.

So two filters in sequence: the right place, and then the right type.

The Netherlands switched in 2015 from selective to universal LGV testing on rectal chlamydia (van Aar, 2020). That did not happen for no reason.

How common is LGV in the Netherlands?

The RIVM and the Amsterdam public health service followed LGV between 2011 and 2017 through the sexual health centres. Over that period the number of diagnoses grew, and above all who was getting it changed.

Source: van Aar, 2020, based on 224,194 consultations. Read that table top to bottom and the pattern jumps out: LGV shifted from a visible disease in men with HIV to an often silent infection in men without it.

Across Europe it is probably badly underdiagnosed. In a multi-country study, 25.6 percent of chlamydia-positive rectal swabs from MSM turned out to be LGV, and the researchers concluded that LGV is substantially missed in Europe (Cole, 2020).

How is LGV treated?

With a longer course of antibiotics than ordinary chlamydia, prescribed by a doctor. In practice that means doxycycline for three weeks rather than one.

That is where the whole point of typing sits.

Treat LGV as ordinary chlamydia and the course is too short, so the infection can return. That is not a theoretical risk; it is the reason the type gets determined separately at all. We test and do not treat, so that course runs through your GP or a sexual health clinic. What happens after a positive result is in tested positive for an STI: what now.

Who is LGV relevant for?

Mainly for men who have receptive anal sex with changing partners. That is the group in which LGV is found almost exclusively in the Netherlands, and the group the surveillance was set up for.

If you have heavy anal symptoms after receptive contact, this belongs on the list of possibilities.

Picture two men who tested positive for chlamydia in the same week, both without symptoms, and both given 1 week of doxycycline.

For one, the sample was typed as well, and it turned out to be LGV. His course went from one week to three. For the other that typing never happened, and he still does not know which type he had. I would always want to know that.

If you have no symptoms but do have that risk profile, the message from the figures above is that being symptom-free says less and less. How often and for what you then test is in STI testing for MSM.

For the wider symptom picture: proctitis: symptoms, causes and testing. Our test for chlamydia, gonorrhoea and trichomonas detects chlamydia with a PCR; LGV typing is an additional step that runs through healthcare, and we would rather say that plainly.

References

• van Aar F, et al. Increasing trends of lymphogranuloma venereum among HIV-negative and asymptomatic men who have sex with men, the Netherlands, 2011 to 2017. Eurosurveillance, 2020. PMID 32290900.
• Cole MJ, et al. Substantial underdiagnosis of lymphogranuloma venereum in men who have sex with men in Europe: preliminary findings from a multicentre surveillance pilot. Sexually Transmitted Infections, 2020. PMID 31235527.
• de Vries HJC, 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. PMID 34057249.
• Chan PA, et al. Extragenital Infections Caused by Chlamydia trachomatis and Neisseria gonorrhoeae: A Review of the Literature. Infectious Diseases in Obstetrics and Gynecology, 2016. PMID 27366021.
• RIVM, STI surveillance Netherlands. Accessed August 2026.

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