Bloody Stool is the Typical Presentation in Rectal Lymphogranuloma Venereum
In rectal lymphogranuloma venereum (LGV), bloody stool is the most common stool characteristic, often accompanied by purulent discharge. This presentation is a key clinical feature that helps distinguish LGV proctitis from other anorectal conditions.
Clinical Presentation of Rectal LGV
Rectal LGV is characterized by:
- Bloody stool: Fresh red blood is typically seen in/on the feces 1
- Purulent rectal discharge
- Painful defecation
- Tenesmus (painful straining)
- Symptoms that can mimic inflammatory bowel disease 1
The bloody stool in LGV proctitis results from inflammation and ulceration of the rectal mucosa caused by invasive L1, L2, or L3 serovars of Chlamydia trachomatis 2. This inflammation leads to mucosal damage and bleeding during defecation.
Endoscopic Findings
Endoscopic examination in patients with rectal LGV typically reveals:
- Mucosal erythema ranging from mild to severe
- Ulcerations that may be superficial or deep with elevated borders
- Purulent exudate
- Well-defined, punched-out ulcerations in up to 80% of patients 1
These endoscopic findings can sometimes be mistaken for other conditions such as inflammatory bowel disease, particularly Crohn's disease 3.
Diagnostic Considerations
LGV proctitis should be suspected in patients presenting with:
- Bloody stool
- Rectal pain and discharge
- Risk factors including:
- Men who have sex with men (MSM)
- HIV-positive status
- History of other sexually transmitted infections
Diagnosis is confirmed through:
- Nucleic acid amplification testing (NAAT) of rectal specimens
- Serologic testing (complement fixation titers >1:64 are consistent with LGV) 2
Complications and Disease Progression
If left untreated, rectal LGV can progress to cause:
- Rectal strictures 3
- Fistula formation, including rectovesical or rectovaginal fistulas 4
- Chronic inflammation leading to fibrosis
Treatment
The recommended treatment for LGV is:
- Doxycycline 100 mg orally twice daily for 21 days 2
- For pregnant or lactating women: erythromycin base 500 mg orally four times daily for 21 days 2
Clinical Pitfalls to Avoid
Misdiagnosis: Rectal LGV can mimic inflammatory bowel disease, colorectal cancer, or other proctitis causes 4
Delayed diagnosis: Due to nonspecific symptoms, diagnosis may be delayed, leading to complications like strictures or fistulas
Inadequate treatment duration: Standard chlamydia treatment (7 days) is insufficient for LGV, which requires 21 days of therapy 2
Failure to test sexual contacts: Partners should be examined and treated even if asymptomatic 2
Incomplete follow-up: Patients should be monitored until complete resolution of symptoms 2
Remember that bloody stool in rectal LGV is a cardinal symptom that should prompt consideration of this diagnosis in at-risk populations, particularly MSM and HIV-positive individuals.