The 5 Red Flags GPs Should Never Ignore in Women's Pelvic Health

Pelvic health concerns are among the most underreported yet prevalent issues in primary care. Many women normalize symptoms, delay seeking help, or feel too embarrassed to raise concerns during consultations. As GPs, your role in early identification and appropriate referral is crucial—not just for symptom management, but for improving quality of life and preventing progression of potentially serious conditions.

While many pelvic floor symptoms respond well to conservative management and physiotherapy, certain presentations warrant immediate attention, further investigation, or specialist referral. Here are five red flags that should never be dismissed or delayed.

1. New or Progressive Pelvic Organ Prolapse with Significant Symptoms

What to look for:

Patients reporting a feeling of heaviness, bulging, or "something coming down" in the vaginal area, particularly if symptoms are worsening or significantly impacting daily activities. While mild prolapse is common—especially postpartum or postmenopausal—rapid progression or severe symptoms require assessment.

Red flags within this presentation:

• Complete prolapse where tissue protrudes beyond the vaginal opening

• Urinary retention or significant voiding dysfunction

• Difficulty with bowel movements or need for manual assistance to empty

• Severe pain or bleeding associated with prolapse

• Rapid deterioration over weeks rather than months or years

  
  

Why it matters:

Severe prolapse can lead to urinary tract obstruction, recurrent UTIs, ulceration, and significant psychological distress. While conservative management with pessaries and pelvic floor physiotherapy is often first-line, some cases require gynecological assessment for surgical options.

Appropriate action:

Refer to gynecology or urogynaecology, particularly if conservative measures have failed or symptoms are severe. Consider pelvic health physiotherapy referral for all cases, as this can improve outcomes whether or not surgery is eventually needed.

2. Persistent Pelvic Pain That Doesn't Respond to Standard Treatment

What to look for:

Chronic pelvic pain lasting more than six months, particularly if it's cyclical, progressively worsening, or unresponsive to typical analgesics and conservative management.

Red flags within this presentation:

• Pain associated with deep dyspareunia (pain during deep penetration)

• Cyclical pain that correlates with menstrual cycle

• Pain accompanied by abnormal bleeding or discharge

• Bowel or bladder symptoms alongside pain (dyschezia, dysuria)

• Pain that significantly limits function, work, or relationships

• Suspected endometriosis, adenomyosis, or other gynecological pathology

  
  

Why it matters:

Chronic pelvic pain is multifactorial, but underlying conditions like endometriosis, pelvic inflammatory disease, interstitial cystitis, or pelvic floor myofascial pain require targeted treatment. Delayed diagnosis can lead to disease progression, fertility issues, and chronic pain sensitization.

Appropriate action:

Consider referral to gynecology, particularly if endometriosis is suspected. Pelvic health physiotherapy is valuable for myofascial pain and pelvic floor hypertonicity. A multidisciplinary approach often yields the best outcomes. Don't dismiss pain as "just IBS" without ruling out other causes.

3. Fecal Incontinence or Significant Bowel Dysfunction

What to look for:

Loss of bowel control, whether solid, liquid, or flatal incontinence. Also watch for fecal urgency that limits leaving the house, or obstructed defecation requiring digital assistance.

Red flags within this presentation:

• Any degree of solid stool incontinence

• New-onset incontinence with no clear cause

• History of obstetric anal sphincter injury (third or fourth-degree tears)

• Rectal bleeding, unexplained weight loss, or change in bowel habit in over-50s

• Neurological symptoms alongside bowel dysfunction

  
  

Why it matters:

Fecal incontinence is profoundly isolating and often goes unreported due to embarrassment. It can indicate sphincter damage, neurological conditions, or colorectal pathology. Early intervention significantly improves outcomes, yet many patients suffer in silence for years.

Appropriate action:

Refer to colorectal surgery or gastroenterology depending on presentation. Exclude sinister pathology with appropriate investigations. Pelvic health physiotherapy can help with sphincter rehabilitation and management strategies. Never dismiss this as "just a consequence of childbirth."

4. Urinary Symptoms with Concerning Features

What to look for:

While stress incontinence and overactive bladder are common, certain urinary presentations need closer evaluation.

Red flags within this presentation:

• Painless visible hematuria (requires urgent two-week wait referral)

• Recurrent UTIs (three or more in six months) despite treatment

• New urinary retention or significant voiding difficulty

• Urinary incontinence accompanied by neurological signs (weakness, numbness, saddle anesthesia)

• Persistent dysuria without infection

• Incontinence with pelvic mass or abnormal examination findings

  
  

Why it matters:

Hematuria can indicate bladder cancer and requires urgent investigation. Recurrent UTIs may suggest underlying structural abnormalities, incomplete emptying, or interstitial cystitis. Neurological symptoms could indicate cauda equina syndrome or other serious pathology.

Appropriate action:

Follow national guidelines for hematuria referrals. Refer recurrent UTIs to urology or urogynaecology. Consider post-void residual scans for retention concerns. Pelvic health physiotherapy is excellent for functional voiding dysfunction and stress/urge incontinence without red flags.

5. Postpartum Complications Beyond "Normal" Recovery

What to look for:

Most women experience some pelvic floor changes after childbirth, but certain presentations indicate complications needing specialist input.

Red flags within this presentation:

• Significant perineal trauma (third or fourth-degree tears) without follow-up

• Persistent wound infection or dehiscence

• Severe pain during intercourse that doesn't improve by 6-12 weeks postpartum

• Fecal or flatal incontinence following delivery

• Urinary incontinence that's significantly limiting function

• Persistent significant diastasis recti with functional limitation

• Signs of postpartum depression or PTSD related to birth trauma

  
  

Why it matters:

Obstetric anal sphincter injuries require specialized follow-up to monitor for long-term sequelae. Birth trauma—physical and psychological—can have lasting impacts if not addressed early. Postpartum women often minimize symptoms, thinking they're "normal" or will resolve with time.

Appropriate action:

Women with third or fourth-degree tears should have consultant-led follow-up and referral to pelvic health physiotherapy. Consider referral to perinatal mental health services if psychological trauma is evident. Don't wait for the six-week check to address concerning symptoms—earlier intervention prevents chronic issues.

Key Principles for GP Referrals

Ask the right questions: Many women won't volunteer pelvic health concerns. Routine screening questions during appropriate consultations can identify hidden issues.

Don't normalize serious symptoms: While some pelvic floor changes are common, "common" doesn't mean "acceptable" or "untreatable."

Collaborate with physiotherapy: Pelvic health physiotherapy is evidence-based, highly effective, and should be considered alongside or before surgical referrals for most functional symptoms.

Maintain a low threshold for specialist input: When in doubt, refer. Early specialist assessment often prevents progression and improves outcomes.

Consider the biopsychosocial impact: Pelvic health conditions affect quality of life, relationships, work, and mental health. Treating them comprehensively improves overall wellbeing.

Building Better Pathways Together

Improving pelvic health outcomes requires strong collaboration between primary care, physiotherapy, and specialist services. GPs are often the first point of contact, and your clinical judgment in recognizing red flags and referring appropriately can be life-changing for patients.

By maintaining awareness of these key presentations and knowing when to refer, you ensure women receive timely, appropriate care—whether that's reassurance and physiotherapy for functional symptoms or urgent investigation for serious pathology.

Let's Collaborate

I love working with GPs to improve pelvic health care pathways and outcomes. If you'd like more resources, clinical guides, or would like to book me for a training session with your practice team, I'd be delighted to help.

👉 Get in touch to discuss how we can work together.