When should I consider referring a patient with pruritus ani to a specialist, and what criteria should guide this decision?

Consider referring a patient with pruritus ani to a specialist if:

• There is diagnostic uncertainty or the cause of pruritus ani is unclear after initial assessment.
• Symptoms are persistent or refractory to initial management, indicating that specialist input may be needed for further investigation or treatment.
• There are signs or symptoms suggestive of underlying serious pathology such as malignancy, inflammatory bowel disease, or other significant anorectal conditions.
• The patient has associated faecal incontinence or other anorectal dysfunction that may require specialist continence services, including pelvic floor muscle training or anorectal physiology studies.
• There is suspicion of dermatological conditions that are difficult to manage or require specialist dermatological advice.

Criteria guiding referral decisions include:

• Presence of red flag symptoms or signs that warrant secondary care investigation, such as those outlined in IBS and cancer referral guidelines.
• Failure to respond to optimal conservative management.
• Need for specialist diagnostic procedures (e.g., endoanal ultrasound, anorectal physiology studies) or treatments not available in primary care.
• Impact on quality of life or psychological wellbeing that may benefit from multidisciplinary specialist input.

In summary, referral should be considered when pruritus ani is persistent, unexplained, associated with other anorectal symptoms, or when initial management in primary care is unsuccessful, to ensure appropriate specialist assessment and management.