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Referral and warning signs
When to refer
Refer for specialist management if: Diagnosis is uncertain. Buboes fail to resolve despite appropriate treatment and partner management. Complications develop (e.g., chronic sinus).
Red flags
- Fluctuant bubo requiring aspiration
- Failure to respond to standard treatment
- Signs suggestive of other pathology (e.g., hernia, malignancy)
Signs and symptoms
- Swollen inguinal and/or femoral lymph nodes (unilateral or bilateral)
- Pain and tenderness in the swollen glands
- Overlying skin may be red and warm
- Swelling may become fluctuant (containing pus)
- May be associated with a current or preceding genital ulcer (though ulcer may be small/transient/unnoticed, especially in LGV)
Risk factors
- Unprotected sexual intercourse
- Multiple sexual partners
- Travel to areas endemic for LGV or Chancroid
Diagnosis
Clinical assessment
History of groin swelling. Examination confirms enlarged, tender inguinal/femoral lymph nodes. Crucially, examine genitals thoroughly for ulcers (current or healed). Rule out other causes of groin swelling (hernia, leg/buttock infection).
Investigations
- Genital examination for ulcers
- Rule out hernia, local infection
- Blood: Syphilis test (RPR/VDRL), HIV test.
- Aspiration of fluctuant bubo: Gram stain, Culture & Sensitivity (C&S), PCR for Chlamydia trachomatis (LGV serovars), Haemophilus ducreyi (specialized labs).
Diagnostic criteria
Presence of inguinal/femoral lymphadenopathy +/- fluctuance, after excluding non-STI causes, managed syndromically, often in conjunction with GUD protocol if ulcer present.
Management
Non-pharmacological management
- Take history and examine (groin, genitals, lower limbs).
- Rule out hernia and local skin/limb infection.
- If fluctuant bubo present: Aspirate pus aseptically through healthy adjacent skin using a large bore needle (Gauge <20). Repeat aspiration every 2 days if needed. DO NOT INCISE AND DRAIN (risk of chronic sinus formation).
- Advise abstinence or condom use.
- Partner notification and treatment.
- Provide health education and risk reduction counseling.
- Offer HIV counseling and testing (HCT).
Pharmacological treatment
- Follow UCG Flowchart (Figure 11):
- 1. If genital ulcer is present: Treat according to GUD protocol (STI004).
- 2. If no genital ulcer present (or treatment covers bubo cause):
- - Give Doxycycline 100 mg PO every 12 hours for 14 days (covers LGV and potentially Chancroid).
- - Alternative: Azithromycin 1g PO single dose (covers Chancroid, less effective for LGV than prolonged Doxycycline).
- - Alternative if partner is pregnant: Erythromycin 500 mg PO every 6 hours for 14 days.
- - Treat sexual partner(s).
- 3. If buboes persist after 14 days AND partner was treated:
- - Continue Doxycycline (or Erythromycin) for another 14 days.
- 4. If no improvement after extended treatment:
- - Refer for specialist management.
Monitoring
Monitor for resolution of swelling and tenderness. Assess need for repeat aspiration if fluctuant.
Complications
- Rupture of bubo with chronic sinus tract formation
- Scarring
- Lymphatic obstruction leading to genital elephantiasis (late complication of LGV)
- Strictures (anal/rectal - late complication of LGV)
Prevention
- Consistent and correct condom use
- Mutual monogamy with an uninfected partner
- Abstinence
- Partner notification and treatment
- Prompt treatment of STIs
Patient education
- Explain the condition and treatment.
- Emphasize completing the full antibiotic course.
- Advise against incising the swelling.
- Explain the need for partner treatment.
- Advise abstinence or condom use.
- Educate on prevention.
- Advise return if swelling worsens or fails to improve.
Uganda-specific notes
Doxycycline is the primary treatment. Aspiration, not incision, is key for fluctuant buboes. Consider LGV and Chancroid as primary causes.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 3, Section 3.2.5, Figure 11