When should I refer a patient with recurrent STIs to a specialist for further evaluation?

Refer a patient with recurrent sexually transmitted infections (STIs) to a specialist for further evaluation in the following situations:

• If the diagnosis is uncertain and requires specialist assessment to confirm or clarify the diagnosis, especially when primary care treatment response is inadequate or there is a persistent lesion needing further investigation such as biopsy ¹.
• If the patient is pregnant at any gestation, as specialist liaison with obstetrics and midwifery is needed to manage risks, including potential antiviral treatment and delivery planning ¹.
• If the patient is immunocompromised or has untreated HIV infection with severe genital herpes or new lesions developing despite antiviral treatment, specialist advice from infectious diseases or sexual health services is required due to risk of antiviral resistance and need for advanced management ¹.
• If there are breakthrough recurrences while the patient is on suppressive antiviral treatment, consider referral to seek specialist advice about optimizing antiviral dosing or alternative management ¹.
• For all suspected syphilis cases, referral to a genito-urinary medicine (GUM) clinic or specialist sexual health service is mandatory due to complexity of diagnosis, treatment, partner notification, and follow-up ².
• If a patient with recurrent STIs is concerned about transmission to new or uninfected sexual partners, referral to specialist sexual health services for partner screening and advice is appropriate ¹.
• If the patient is systemically unwell or has suspected severe complications that cannot be managed in primary care, emergency hospital admission and specialist care should be arranged ¹.

These referral criteria ensure appropriate specialist evaluation, management, and support for complex or high-risk cases of recurrent STIs, in line with UK national guidelines ¹,²,³.