When should I consider referring a patient with chronic pelvic pain to a specialist, and what criteria should guide this decision?

Consider referring a patient with chronic pelvic pain to a specialist when:

• They have symptoms suggestive of endometriosis, such as chronic pelvic pain, period-related pain affecting daily activities, deep pain during or after sexual intercourse, cyclical gastrointestinal or urinary symptoms, or infertility associated with these symptoms ¹.
• There is a suspicion of complex or severe endometriosis requiring multidisciplinary management, including access to gynaecologists with advanced laparoscopic skills, colorectal surgeons, urologists, specialist nurses, and pain management services ¹.
• Symptoms persist despite initial management in primary care or when the diagnosis is uncertain and requires specialist imaging or advanced diagnostic facilities ¹.
• There are signs or symptoms suggestive of mesh-related complications (e.g., pain, vaginal problems, urinary or bowel symptoms) following pelvic surgery, warranting referral to a urogynaecologist, urologist, or colorectal surgeon ².
• There is a suspicion of pelvic or abdominal mass, or features raising concern for cancer (e.g., persistent or frequent pelvic pain especially in women aged 50 and over), which requires urgent specialist assessment or suspected cancer pathway referral ³.
• Pelvic floor dysfunction is suspected and initial conservative management has not resolved symptoms, or specialist assessment is needed for complex cases ⁴.

Referral criteria should be guided by:

• Presence of specific symptoms and signs indicating endometriosis or other pelvic pathology ¹.
• Failure to respond to primary care management or worsening symptoms ¹,².
• Need for multidisciplinary assessment and advanced diagnostic or surgical interventions ¹,².
• Red flag features suggestive of malignancy or serious pathology requiring urgent investigation ³.
• Complex pelvic floor dysfunction requiring specialist input ⁴.