Conditions · Infectious and tropical diseases
Granuloma inguinale (donovanosis) !
Donovanosis is a rare sexually transmitted infection that causes painless, beefy-red genital ulcers that bleed easily and slowly destroy tissue if untreated.
Updated 2026-11-01
Structures involved
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Why it happens
- Granulomatous inflammation: caseating vs non-caseating, the causes to know
- Chronic inflammation: causes, cells and features
- How the lymphatic system works
What it is
A chronic, progressive sexually transmitted infection by Klebsiella granulomatis that produces painless, highly vascular genital or perianal ulcers. Despite the name, true inguinal lymph-node enlargement is absent; subcutaneous granulomas in the groin form pseudobuboes.
Who gets it
Rare worldwide and in Colombia. Sporadic cases occur in India, southern Africa, Papua New Guinea, the Caribbean and parts of South America. It is more frequent in people with low access to health care and is often found together with other sexually transmitted infections.
Causes
- Klebsiella granulomatis (formerly Calymmatobacterium granulomatis), an intracellular Gram-negative bacillus
- Mainly sexual transmission; occasional non-sexual and perinatal spread
- Long incubation, usually weeks (from a few days to several months)
Risk factors
- Unprotected sex in or with partners from endemic areas
- Low socioeconomic status and poor genital hygiene
- Other genital ulcer diseases or HIV infection
- Male sex in most reported series
Pathophysiology
The bacteria enter through small breaks in genital skin and multiply inside macrophages, producing a granulomatous reaction rich in plasma cells and new blood vessels. This makes a fleshy, friable, beefy-red ulcer that enlarges slowly by contiguous spread. Lymph nodes are generally not involved; the groin swellings are subcutaneous granulomas. Chronic disease can cause scarring, lymphatic blockage and genital swelling.
Classification
- Ulcerogranulomatous (most common): beefy-red, non-tender ulcers that bleed on touch
- Hypertrophic or verrucous: raised, wart-like lesions
- Necrotic: deep, foul-smelling destructive ulcers
- Sclerotic or cicatricial: dry ulcers that leave fibrous scars
Symptoms and signs
- One or more painless nodules that break down into a slowly growing ulcer
- Beefy-red, granular ulcer base with rolled edges that bleeds easily
- Lesions on the penis, scrotum, labia, vulva, perineum or perianal area
- Groin swellings (pseudobuboes) without true lymphadenopathy
- Spreading lesions by contact (kissing lesions) on opposite skin surfaces
Diagnosis
- Clinical
- A painless, beefy-red, bleeding genital ulcer that grows slowly in a person with possible exposure in an endemic area. Every genital ulcer needs testing for syphilis, herpes and HIV.
- Tests
- Donovan bodies (dark-staining bacteria inside macrophages, safety-pin appearance) on a tissue crush preparation or biopsy stained with Giemsa or Wright stain. Culture is very difficult; PCR is available in research or reference settings. Biopsy also rules out cancer in long-standing lesions. Serology for syphilis and HIV testing are always done.
- Imaging
- Not needed for diagnosis; imaging is used only when spread to pelvic organs or bone is suspected.
Differential diagnosis
- Primary or secondary syphilis (chancre or condylomata lata)
- Chancroid (painful ulcer with tender suppurating nodes)
- Genital herpes (painful grouped vesicles and erosions)
- Lymphogranuloma venereum (small transient ulcer with large tender nodes)
- Squamous cell carcinoma of the penis or vulva
- Cutaneous amoebiasis or tuberculosis
Goal of treatment
Cure the infection and stop tissue destruction by treating until all lesions heal, and test and treat partners and coexisting infections.
Treatment
- Medical
- Azithromycin is the first-line antibiotic, given for at least three weeks and until all lesions have fully healed.
- Medical
- Alternatives include doxycycline, trimethoprim-sulfamethoxazole and erythromycin; macrolides are preferred in pregnancy. A second antibiotic may be added if lesions do not respond within the first days.
- Follow-up
- Follow-up until complete healing, because relapse can occur months later; HIV and syphilis testing, and examination and treatment of sex partners from the previous 60 days.
Complications
- Extensive genital destruction and scarring
- Genital lymphoedema (pseudoelephantiasis)
- Urethral, vaginal or anal stenosis
- Secondary bacterial infection
- Squamous cell carcinoma in long-standing lesions
- Dissemination to bone, liver or the mouth (rare)
Prognosis
Curable with antibiotics, and early lesions heal with little scarring. Late disease may leave deformity, and relapse is possible up to 18 months after apparently successful treatment.
Prevention
- Condom use and reduction of sexual partners
- Prompt evaluation of any genital ulcer
- Examination and treatment of sex partners
Test yourself
Think of the answer, then tap the question to see it.
Which organism causes granuloma inguinale?
Klebsiella granulomatis, an intracellular Gram-negative bacillus.
How is the ulcer of donovanosis classically described?
Painless, beefy-red, granular and highly vascular, bleeding easily on contact.
What is seen on a tissue smear or biopsy that confirms donovanosis?
Donovan bodies: dark-staining bacteria inside macrophages, with a safety-pin appearance.
How do the groin swellings of donovanosis differ from those of chancroid?
They are subcutaneous granulomas (pseudobuboes), not enlarged lymph nodes; chancroid causes true tender suppurative lymphadenitis.
How long is antibiotic treatment continued in donovanosis?
At least three weeks and until all lesions have completely healed.
Related conditions
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Granuloma Inguinale (Donovanosis) - STI Treatment Guidelines (Centers for Disease Control and Prevention, 2021); Donovanosis (granuloma inguinale): MedlinePlus Medical Encyclopedia (MedlinePlus (U.S. National Library of Medicine), 2024).
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