Lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) caused by the L-serovars of Chlamydia trachomatis. Like most bacterial STIs it remains prevalent worldwide, especially in tropical and resource-poor regions. In recent years it has also become recognized in populations of men who have sex with men (MSM) in the developed world, in whom it is now an important cause of proctitis in Europe and the USA. In contrast to tropical LGV that typically causes ulcer-adenopathy syndrome, MSM usually present with severe proctitis and a strong association with HIV infection exists. Conflicting data exist regarding the prevalence of asymptomatic MSM infection and our understanding of the exact modes of transmission remains incomplete. LGV proctitis can be confused clinically with other rectal STIs, as well as non-infectious enteropathies, leading to diagnostic delay and persistent morbidity. Modern nucleic acid tests have enabled more accurate diagnosis of LGV and allow it to be distinguished from the more common but less pathogenic non-LGV-serovar infections. Prompt antibiotic treatment with a 3-week course of oral doxycycline is effective and curative, yet broader awareness among clinicians is needed to enable appropriate investigation and management, and the interruption of onward spread.