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Przewlekły ból j±dra - trudny problem klinicznyOddział Urologii w Puławach
ordynator oddziału: lek. med. Tadeusz Palec Klinika CMKP w Warszawie kierownik kliniki: prof. dr hab. n. med. Andrzej Borówka Zespół kliniczny, któremu po¶więcony jest ten artykuł, stanowi w moim przekonaniu trudny problem diagnostyczny i terapeutyczny, z którym - prędzej, czy póĽniej – zetknie się każdy urolog. Dotychczas nie udało się jednoznacznie sformułować zaleceń odno¶nie postępowania w przypadku tego zespołu. Różnorodne postępowanie diagnostyczne i lecznicze obejmuje działania zachowawcze oraz niezwykle radykalne.
Rozpoznanie Unaczynienie i unerwienie j±draNaczynia krwiono¶ne j±dra bior± swój pocz±tek w miejscu, w którym pierwotnie znajduje się zawi±zek j±dra w życiu płodowym. Tętnica j±drowa odchodzi od aorty brzusznej i biegnie na przedniej powierzchni mię¶nia lędĽwiowego większego, krzyżuje moczowód od przodu, a następnie przechodzi przez kanał pachwinowy w obrębie powrózka nasiennego i dociera do j±dra znajduj±cego się w mosznie. Tętnica j±drowa zaopatruje j±dro i głowę naj±drza. W obrębie j±dra zespala się z dwiema mniejszymi tętnicami: tętnic± nasieniowodu, odchodz±c± zazwyczaj od tętnicy biodrowej wewnętrznej oraz z tętnic± dĽwigacza j±dra, odchodz±c± od tętnicy nabrzusznej dolnej. Żyły odprowadzaj±ce krew z j±dra towarzysz± tętnicom. Po zespoleniu z żyłami naj±drza tworz± splot wiciowaty (plexus pampiniformis), będ±cy największym składnikiem powrózka nasiennego. Ze splotu wiciowatego odchodz± dwie gałęzie żylne, z których powstaje pojedyncza żyła j±drowa. Prawa żyła j±drowa uchodzi do żyły głównej dolnej, za¶ lewa do żyły nerkowej lewej. Żyły j±drowe zespalaj± się z żyłami dĽwigacza j±dra, które odbieraj± krew z osłonek j±dra. J±dro jest obficie zaopatrzone w naczynia chłonne. W obrębie powrózka biegnie 4-6 pni chłonnych, które uchodz± do węzłów lędĽwiowych. Dzięki istnieniu zespoleń, chłonka z j±dra spływa również do powierzchownych węzłów chłonnych pachwinowych. Unerwienie współczulne j±dra wywodzi się z segmentów rdzenia Th10-L1. Włókna nerwowe towarzysz± naczyniom krwiono¶nym, które wchodz± w skład powrózka nasiennego. Po przej¶ciu przez osłonkę biaław± wnikaj± w gł±b j±dra. Główn± ich funkcj± jest unerwienie tętnic oraz mię¶ni gładkich osłonki białawej j±dra. Do¶rodkowe włókna współczulne odbieraj±ce bodĽce z nocyceptorów tworz± splot współczulny, otaczaj±cy tętnicę i żyły j±drowe. Nerwy zaopatruj±ce j±dro pochodz± ze splotu trzewnego. Biegn± dalej czę¶ciowo przez splot nerkowy i towarzysz± tętnicy j±drowej, tworz±c splot j±drowy. Nerwy te prowadz± włókna czuciowe do osłonek surowiczych j±dra oraz włókna współczulne i przywspółczulne zaopatruj±ce naczynia i mię¶nie przewodu naj±drza oraz nasieniowodu. Doznania bólowe powstaj±ce w j±drze przenoszone s± przez aferentne włókna somatyczne i autonomiczne, które towarzysz± naczyniom j±drowym. Włókna te wchodz± w skład nerwu biodrowo-pachwinowego oraz gałęzi płciowej nerwu płciowo-udowego. Włókna somatyczne warstwy ¶ciennej oraz trzewnej osłonki pochwowej j±dra i mię¶nia dĽwigacza j±dra biegn± w gałęzi płciowej nerwu płciowo-udowego do segmentów L1-L2. Unerwienie autonomiczne j±der dochodzi do zwojów przedkrzyżowych T10-L2, a z naj±drzy osobnymi włóknami do segmentów T10-L1. Ponadto, inne włókna somatyczne unerwiaj±ce osłonkę pochwow± j±dra oraz skórę moszny tworz± nerwy mosznowe tylne, biegn±ce do segmentów S2-S3 rdzenia.
Etiopatogeneza przewlekłego bólu j±draPrzyczyny CTP s± mniej znane od przyczyn bólu ostrego. Swoistymi czynnikami wywołuj±cymi CTP s±:
Na podstawie wielu doniesień oraz praktyki klinicznej wiadomo, że przepuklina pachwinowa, wodniak j±dra oraz żylaki powrózka nasiennego bardzo rzadko s± przyczyn± bólu j±dra. Towarzyszy im raczej trudny do sprecyzowania dyskomfort w obrębie moszny. CTP często jest skutkiem operacji, przeprowadzonej w obrębie moszny - najczę¶ciej wazektomii. Według wielu autorów 15-30% chorych, u których przeprowadzono ten zabieg, zgłasza ból j±dra o charakterze przewlekłym. Przyczyn± CTP mog± być powtarzaj±ce się urazy j±der, zbyt częste samobadanie (self-palpation orchitis) przez osoby z karcynofobi± oraz choroby generuj±ce ból przeniesiony (np. kamień w ¶rodkowym lub dolnym odcinku moczowodu, zespół korzeniowy, tętniak aorty b±dĽ tętnicy biodrowej wspólnej). W takich sytuacjach leczenie jest zazwyczaj przyczynowe. Znacznie trudniej jest leczyć chorych, u których nie udaje się znaleĽć konkretnej przyczyny CTP. RozpoznanieZasadnicze znaczenie dla wła¶ciwej oceny chorych na CTP maj± dokładnie zebrany wywiad choroby oraz badanie przedmiotowe. Chorzy s± zwykle spięci, niespokojni i zmieszani oraz przekonani, że problem, z którym zgłaszaj± się do lekarza, jest wyj±tkowo poważny. Na ogół zanim trafi± do urologa konsultowani s± przez kilku lekarzy, co utwierdza ich w przekonaniu o powadze sytuacji, zwłaszcza że oferowana im pomoc jest zwykle nieskuteczna. Przeprowadza się wiele kosztownych badań, które jedynie wyj±tkowo wykazuj± jakie¶ nieprawidłowo¶ci w obrębie miednicy mniejszej, jamy brzusznej lub moszny. Costabile i wsp. u 48 mężczyzn z CTP, głównie młodych, stwierdzili, że jedynie wyniki 2 spo¶ród 209 wykazały istotne nieprawidłowo¶ci (<1%). Uważaj± oni, że wykonywanie badań diagnostycznych u chorych na CTP należy ograniczyć, nie tylko w celu obniżenia kosztów, ale także w celu zmniejszenia ryzyka wyst±pienia powikłań po badaniach. Ponadto, istotne jest zaniechanie wykonywania wielu skomplikowanych badań, by nie potęgować obaw pacjentów co do przyczyn bólu. Aby prawidłowo zaplanować diagnostykę, konieczne jest dokładne zebranie wywiadu. Podczas rozmowy z chorym należy ustalić pocz±tek powstania dolegliwo¶ci, umiejscowienie bólu i czas jego trwania oraz okoliczno¶ci zwi±zane z jego wyst±pieniem. Istotna jest ocena czynno¶ci seksualnych, występowania sytuacji stresowych oraz stanów lękowych. Nie mniej ważne jest badanie fizykalne pr±cia, moszny, j±der, naj±drzy, powrózków nasiennych oraz okolic pachwin i dołów biodrowych. Istotne jest również badanie palcem przez odbytnicę w celu okre¶lenia stanu stercza i odbytnicy. Zaleca się także wykonanie usg jamy brzusznej, ze szczególnym zwróceniem uwagi na nerki i okolicę pozaotrzewnow±, odpowiadaj±c± stronie bolesnego j±dra. Wskazana jest usg przezodbytnicza stercza i pęcherzyków nasiennych. Nie można zapominać, że czasami przyczyn± bólu j±dra jest kamica moczowodowa, zwłaszcza ¶rodkowego odcinka. Ból j±dra zazwyczaj towarzyszy kolce nerkowej, ale niekiedy ból j±dra może stać się przewlekły po ust±pieniu bólu nerki, jednak w sytuacji utrzymywania się kamienia w moczowodzie. Dlatego warto wykonać przegl±dowe zdjęcie jamy brzusznej, pamiętaj±c oczywi¶cie o możliwo¶ci istnienia kamicy bezcieniowej. Badania laboratoryjne stosowane w diagnostyce CTP obejmuj± badanie ogólne i bakteriologiczne moczu, posiew nasienia oraz próbę Mearesa-Stameya. W celu ostatecznego wyja¶nienia pochodzenia bólu j±dra, chorego powinien skonsultować ortopeda, aby wykluczyć lub potwierdzić ortopedyczne podłoże choroby (ból przeniesiony). LeczenieZachowawcze leczenie CTP obejmuje podawanie antybiotyków wraz z niesteroidowymi lekami przeciwzapalnymi, stosowanie małych dawek leków przeciwdepresyjnych, przezskórn± stymulację nerwów (TENS) lub akupunkturę. Jednak skuteczno¶ć takiego leczenia ocenia się na 10-30%. Z kolei tradycyjne leczenie operacyjne sprowadzało się często do usunięcia naj±drza, pomimo braku obiektywnych przesłanek ¶wiadcz±cych o patologii w jego obrębie. Je¶li takie postępowanie nie przynosiło spodziewanych efektów, urolodzy często uciekali się do usunięcia j±dra. Jednak odsetek powodzeń leczenia tego rodzaju wynosił tylko 40-70%. Wobec tego rozpoczęto poszukiwanie skuteczniejszych metod leczenia przewlekłego idiopatycznego bólu j±dra. Jedn± z nich jest propagowane przez niektórych urologów (Vest, Choa, Swami, Heidenreich) mikrochirurgiczne odnerwienie j±dra. Doniesienia o największym do¶wiadczeniu w stosowaniu tej metody opublikowali dwaj niemieccy urolodzy - Heidenreich i Olbert. Zastosowali j± u 35 chorych, uzyskuj±c powodzenie u 34 (96%) z nich. Technika mikrochirurgicznego odnerwienia j±draPrzed operacj± wykonuje się blokadę powrózka nasiennego (10 ml lignokainy i 40 mg metyloprednizolonu) – ust±pienie bólu j±dra przekonuje, że odnerwienie j±dra będzie skuteczne. Operację wykonuje się z cięcia nad kanałem pachwinowym. Po uwolnieniu powrózka nasiennego rozpoczyna się preparowanie jego struktur. Na wstępie oddziela się nasieniowód z towarzysz±c± mu tętnic±. Podobnie postępuje się z włóknami mię¶nia dĽwigacza j±dra. Następnie, z pomoc± szkieł powiększaj±cych lub mikroskopu operacyjnego, należy zidentyfikować i wypreparować tętnicę j±drow±.
Czynno¶ć tę ułatwia zastosowanie ¶rodków powoduj±cych rozszerzenie naczyń (np. lignokainy lub papaweryny). Po wypreparowaniu tętnicy j±drowej przecina się kolejno wszystkie struktury powrózka nasiennego, z wyj±tkiem nasieniowodu, tętnicy j±drowej oraz 1-2 naczyń chłonnych. Do zniszczenia tych elementów wykorzystuje się diatermię bipolarn±. Ponadto, stosuj±c tę diatermię, niszczy się przydankę tętnicy j±drowej na długo¶ci 2-3 cm, co skutkuje uszkodzeniem włókien współczulnych oplataj±cych tętnicę. Przecięcie mię¶nia dĽwigacza j±dra powoduje zniszczenie włókien gałęzi płciowej nerwu płciowo-udowego.
Literatura
Materiały wykorzystane w pracy użyte za wiedz± i zgod± prof. Axla Heidenreicha. komentarze
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I'll be honest I didn't lose my Keys.
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Best,
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Merry Christmas.
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Demetria Wolford
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If you’ve been trying to improve your site’s ranking and need a little boost, I’ve had some success with dofollow backlinks. If you’re curious, feel free to reach out: https://rebrand.ly/SEO-backlinks-Miranda
Hey,
I understand how tough it can be to boost your website’s ranking. I specialize in on-page SEO optimization and have a 4.9 rating from 4,600 completed orders.
If you’re interested, you can order my service here: https://bit.ly/randy-seo-optimizations
Plus, I offer a $1,000 refund if you’re not satisfied—your trust is important to me.Looking forward to connecting!
Best,
Randy M.
Hey,
I understand how tough it can be to boost your website’s ranking. I specialize in on-page SEO optimization and have a 4.9 rating from 4,600 completed orders.
If you’re interested, you can order my service here: https://bit.ly/randy-seo-optimizations
Plus, I offer a $1,000 refund if you’re not satisfied—your trust is important to me.Looking forward to connecting!
Best,
Randy M.
Hey,
I understand how tough it can be to boost your website’s ranking. I specialize in on-page SEO optimization and have a 4.9 rating from 4,600 completed orders.
If you’re interested, you can order my service here: https://bit.ly/randy-seo-optimizations
Plus, I offer a $1,000 refund if you’re not satisfied—your trust is important to me.Looking forward to connecting!
Best,
Randy M.
Hey,
I understand how tough it can be to boost your website’s ranking. I specialize in on-page SEO optimization and have a 4.9 rating from 4,600 completed orders.
If you’re interested, you can order my service here: https://bit.ly/randy-seo-optimizations
Plus, I offer a $1,000 refund if you’re not satisfied—your trust is important to me.Looking forward to connecting!
Best,
Randy M.
Hey,
I understand how tough it can be to boost your website’s ranking. I specialize in on-page SEO optimization and have a 4.9 rating from 4,600 completed orders.
If you’re interested, you can order my service here: https://bit.ly/randy-seo-optimizations
Plus, I offer a $1,000 refund if you’re not satisfied—your trust is important to me.Looking forward to connecting!
Best,
Randy M.
Hey,
I understand how tough it can be to boost your website’s ranking. I specialize in on-page SEO optimization and have a 4.9 rating from 4,600 completed orders.
If you’re interested, you can order my service here: https://bit.ly/randy-seo-optimizations
Plus, I offer a $1,000 refund if you’re not satisfied—your trust is important to me.Looking forward to connecting!
Best,
Randy M.
Hey,
I understand how tough it can be to boost your website’s ranking. I specialize in on-page SEO optimization and have a 4.9 rating from 4,600 completed orders.
If you’re interested, you can order my service here: https://bit.ly/randy-seo-optimizations
Plus, I offer a $1,000 refund if you’re not satisfied—your trust is important to me.Looking forward to connecting!
Best,
Randy M.
Hey,
I understand how tough it can be to boost your website’s ranking. I specialize in on-page SEO optimization and have a 4.9 rating from 4,600 completed orders.
If you’re interested, you can order my service here: https://bit.ly/randy-seo-optimizations
Plus, I offer a $1,000 refund if you’re not satisfied—your trust is important to me.Looking forward to connecting!
Best,
Randy M.
Hey,
I understand how tough it can be to boost your website’s ranking. I specialize in on-page SEO optimization and have a 4.9 rating from 4,600 completed orders.
If you’re interested, you can order my service here: https://bit.ly/randy-seo-optimizations
Plus, I offer a $1,000 refund if you’re not satisfied—your trust is important to me.Looking forward to connecting!
Best,
Randy M.
Hey,
I understand how tough it can be to boost your website’s ranking. I specialize in on-page SEO optimization and have a 4.9 rating from 4,600 completed orders.
If you’re interested, you can order my service here: https://bit.ly/randy-seo-optimizations
Plus, I offer a $1,000 refund if you’re not satisfied—your trust is important to me.Looking forward to connecting!
Best,
Randy M.
Hey,
I have an offer you can’t refuse.
I’m here to improve your SEO and get your site noticed—for free.
No payment, no risk—I’m sure you’ll love the results.I specialize in on-page SEO optimization.
If you’re interested, you can contact me here: https://bit.ly/randy-seo-optimizations
Plus, I offer a extra $1,000 refund if you’re not satisfied—your trust is important to me.
Or if you know any other people who might be interested please forward it to them.
Best,
Randy M.
Hey,
I have an offer you can’t refuse.
I’m here to improve your SEO and get your site noticed—for free.
No payment, no risk—I’m sure you’ll love the results.I specialize in on-page SEO optimization.
If you’re interested, you can contact me here: https://bit.ly/randy-seo-optimizations
Plus, I offer a extra $1,000 refund if you’re not satisfied—your trust is important to me.
Or if you know any other people who might be interested please forward it to them.
Best,
Randy M.
Hey,
I have an offer you can’t refuse.
I’m here to improve your SEO and get your site noticed—for free.
No payment, no risk—I’m sure you’ll love the results.I specialize in on-page SEO optimization.
If you’re interested, you can contact me here: https://bit.ly/randy-seo-optimizations
Plus, I offer a extra $1,000 refund if you’re not satisfied—your trust is important to me.
Or if you know any other people who might be interested please forward it to them.
Best,
Randy M.
Hey,
I have an offer you can’t refuse.
I’m here to improve your SEO and get your site noticed—for free.
No payment, no risk—I’m sure you’ll love the results.I specialize in on-page SEO optimization.
If you’re interested, you can contact me here: https://bit.ly/randy-seo-optimizations
Plus, I offer a extra $1,000 refund if you’re not satisfied—your trust is important to me.
Or if you know any other people who might be interested please forward it to them.
Best,
Randy M.
Hey,
I have an offer you can’t refuse.
I’m here to improve your SEO and get your site noticed—for free.
No payment, no risk—I’m sure you’ll love the results.I specialize in on-page SEO optimization.
If you’re interested, you can contact me here: https://bit.ly/randy-seo-optimizations
Plus, I offer a extra $1,000 refund if you’re not satisfied—your trust is important to me.
Or if you know any other people who might be interested please forward it to them.
Best,
Randy M.
Hey,
I have an offer you can’t refuse.
I’m here to improve your SEO and get your site noticed—for free.
No payment, no risk—I’m sure you’ll love the results.I specialize in on-page SEO optimization.
If you’re interested, you can contact me here: https://bit.ly/randy-seo-optimizations
Plus, I offer a extra $1,000 refund if you’re not satisfied—your trust is important to me.
Or if you know any other people who might be interested please forward it to them.
Best,
Randy M.
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped OutboundGen get to the first search result when someone searches for “outbound.”
Check out my Fiverr profile for more details: https://bit.ly/randy-seo-optimizations
Let me know if you’d like to discuss further!
Best,
Randy
M
Full Stack Digital Marketer | Ex-Googler
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped OutboundGen get to the first search result when someone searches for “outbound.”
Check out my Fiverr profile for more details: https://bit.ly/randy-seo-optimizations
Let me know if you’d like to discuss further!
Best,
Randy
M
Full Stack Digital Marketer | Ex-Googler
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped OutboundGen get to the first search result when someone searches for “outbound.”
Check out my Fiverr profile for more details: https://bit.ly/randy-seo-optimizations
Let me know if you’d like to discuss further!
Best,
Randy
M
Full Stack Digital Marketer | Ex-Googler
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped OutboundGen get to the first search result when someone searches for “outbound.”
Check out my Fiverr profile for more details: https://bit.ly/randy-seo-optimizations
Let me know if you’d like to discuss further!
Best,
Randy
M
Full Stack Digital Marketer | Ex-Googler
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped OutboundGen get to the first search result when someone searches for “outbound.”
Check out my Fiverr profile for more details: https://bit.ly/randy-seo-optimizations
Let me know if you’d like to discuss further!
Best,
Randy
M
Full Stack Digital Marketer | Ex-Googler
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped Nile Cruisers get to the first search result when someone searches for “cruise in newyork”
Check out my Fiverr profile for more details: https://bit.ly/monthlyseo-miranda
Let me know if you’d like to discuss further!
Best,
Miranda
SEO Expert
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped Nile Cruisers get to the first search result when someone searches for “cruise in newyork”
Check out my Fiverr profile for more details: https://bit.ly/monthlyseo-miranda
Let me know if you’d like to discuss further!
Best,
Miranda
SEO Expert
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped Nile Cruisers get to the first search result when someone searches for “cruise in newyork”
Check out my Fiverr profile for more details: https://bit.ly/monthlyseo-miranda
Let me know if you’d like to discuss further!
Best,
Miranda
SEO Expert
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped Nile Cruisers get to the first search result when someone searches for “cruise in newyork”
Check out my Fiverr profile for more details: https://bit.ly/monthlyseo-miranda
Let me know if you’d like to discuss further!
Best,
Miranda
SEO Expert
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped Nile Cruisers get to the first search result when someone searches for “cruise in newyork”
Check out my Fiverr profile for more details: https://bit.ly/monthlyseo-miranda
Let me know if you’d like to discuss further!
Best,
Miranda
SEO Expert
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped Nile Cruisers get to the first search result when someone searches for “cruise in newyork”
Check out my Fiverr profile for more details: https://bit.ly/monthlyseo-miranda
Let me know if you’d like to discuss further!
Best,
Miranda
SEO Expert
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped Nile Cruisers get rank top page on google and 100k visitor per month.
Check out my Fiverr profile for more details: https://bit.ly/monthlyseo-miranda
Let me know if you’d like to discuss further!
Best,
Miranda
SEO Expert
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped Nile Cruisers get rank top page on google and 100k visitor per month.
Check out my Fiverr profile for more details: https://bit.ly/monthlyseo-miranda
Let me know if you’d like to discuss further!
Best,
Miranda
SEO Expert
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped Nile Cruisers get rank top page on google and 100k visitor per month.
Check out my Fiverr profile for more details: https://bit.ly/monthlyseo-miranda
Let me know if you’d like to discuss further!
Best,
Miranda
SEO Expert
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped Nile Cruisers get rank top page on google and 100k visitor per month.
Check out my Fiverr profile for more details: https://bit.ly/monthlyseo-miranda
Let me know if you’d like to discuss further!
Best,
Miranda
SEO Expert
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped Nile Cruisers get rank top page on google and 100k visitor per month.
Check out my Fiverr profile for more details: https://bit.ly/monthlyseo-miranda
Let me know if you’d like to discuss further!
Best,
Miranda
SEO Expert
Hey,
Noticed that your site isn’t ranking on the first page of Google. Are you currently doing anything to address that?
I specialize in helping website like yours rank on the first page within 90 days through proven SEO strategies—or you don’t pay.
We just helped Nile Cruisers get rank top page on google and 100k visitor per month.
Check out my Fiverr profile for more details: https://bit.ly/monthlyseo-miranda
Let me know if you’d like to discuss further!
Best,
Miranda
SEO Expert
Hi,
I came across your website and noticed that your current logo design has potential for improvement.
I’d love to offer you my services to help refine your brand identity and make it stand it out on google.
I’m committed to providing personalized service to ensure that you’re fully satisfied with the final product.
If you’re interested in discussing further, please contact me here : https://bit.ly/premium-logo-design
Or if you know any other people who might be interested, please forward it to them.
Thanks for considering my services.
Regards,
Jawad
Hi,
I came across your website and thought Deel could be a great fit for your business.
It’s a platform that makes managing payroll, contracts, taxes, and compliance easy. Whether you’re hiring locally or globally, Deel helps automate payments, stay compliant with tax laws, and handle accounts across countries.
Check it out here: https://bit.ly/deel-for-business
Or, if you know anyone else who might benefit, feel free to forward this to them!
Best,
Louis
Hi,
I came across your website and thought Deel could be a great fit for your business. It’s a platform that makes managing payroll, contracts, taxes, and compliance easy. Whether you’re hiring locally or globally, Deel helps automate payments, stay compliant with tax laws, and handle accounts across countries.
Check it out here:https://bit.ly/deel-for-business
Or, if you know anyone else who might benefit, feel free to forward this to them!
Best,
Riley Baggett
Hi,
I came across your website on Google and noticed your logo could use a little upgrade.
A weak logo can make your brand forgettable, and that’s the last thing you want.
I can help design a logo that grabs attention and sticks with your customers.
Let’s give your brand the look it deserves.
Reach me here: https://bit.ly/custom-logo-designz
Cheers,
Jawad
Hi,
I came across your website on google and noticed it could benefit from more traffic. I offer SEO services on Fiverr that can help improve your Google rankings, and I’m confident you’ll see results within 2 months. If not, I’ll give you a full refund with fiverr Terms and condition.
Check out my services on Fiverr here: https://bit.ly/work-with-randym
Feel free to share this with anyone else who may need help.
Randy M
Hi,
I came across your website on Google and noticed a small issue with your logo and it doesn’t fully reflect the potential of your brand.
I’d love to help you fix this and create a logo that truly represents your business.
If you’d like to work together, you can reach me here on fiverr : https://bit.ly/work-with-jawad
Feel free to share this with anyone else who might need a better logo too.
Best regards,
Jawad
Hi,
I came across your website and thought Deel might be a great fit for your business. It’s a simple way to handle payroll, contracts, and compliance—whether you’re hiring locally or globally.
Deel automates payments, takes care of tax laws, and makes managing teams across countries hassle-free.
Right now, they’re offering a free trial for teams of 1-200 employees, so you can try it out risk-free.
Check it out here: https://get.deel.com/try-it-free
And if you know anyone else who might benefit, feel free to share this with them!
Best,
Courtney Praed
Immediate attention needed
Hey, I’m Miguel. I saw your website and noticed a few small issues. It’s a little hard to use, the design looks a bit old, and it takes time to load.
These things can make visitors leave before they even check out what you offer.
I’d love to help fix this and make your website look better and work smoother.
Let’s chat!
You can reach me here: https://bit.ly/work-with-Miguel
Also, if you know someone who might need help with their website, feel free to forward this email to them!
Talk soon,
Miguel M
Hey there,
I came across your website, and while it looks great, your logo doesn’t quite match your brand’s vibe.
First impressions matter, a quick update could make a huge difference.
I design logos that align perfectly with your brand.
Want me to take a look?
Check out my work here: https://bit.ly/logo-gallery-michael
Best,
Michael
Hey there,
I came across your website, and while it looks great, your logo doesn’t quite match your brand’s vibe.
First impressions matter, a quick update could make a huge difference.
I design logos that align perfectly with your brand.
Want me to take a look?
Check out my work here: https://bit.ly/logo-gallery-michael
Best,
Michael
Hey there,
I came across your website and noticed it loads slowly, isn’t mobile-friendly, and looks outdated. A modern redesign can help you keep visitors engaged and convert more customers.
I specialize in fast, high-quality website redesigns. Want me to take a quick look?
Check out my work here: https://rebrand.ly/portfolio-yanislav
Best,
Yanislav
Hey there,
I came across your website, it looks good, but it’s probably not showing up on Google. That means people can’t find it easily.
I help websites get seen more and bring in more visitors. One site I worked on got 3x more people in just 3 months.
Check out my work here: https://bit.ly/randym-portfolio
Best,
Randy
Hey there,
I came across your website, and while it looks great, your logo doesn’t quite match your brand’s vibe.
First impressions matter, a quick update could make a huge difference.
I design logos that align perfectly with your brand.
Want me to take a look?
Check out my work here: https://bit.ly/david-projects
David
Hey there,
I came across your website, and while it looks great, it’s not showing up where it should on Google. A few SEO fixes like speeding up the site, adding meta tags, and improving keyword focus could make a big difference in traffic and leads.
I offer monthly SEO that helps businesses grow steadily. Want me to take a look?
Check out my work here: https://bit.ly/jacob-projects
Best,
Jacob
Hey there,
I came across your website, and while it looks great, your logo doesn’t quite match your brand’s vibe.
First impressions matter, a quick update could make a huge difference.
I design logos that align perfectly with your brand.
Want me to take a look?
Check out my work here: https://bit.ly/projects-kassou
kassou
Hey there,
I came across your website, and while it looks great, your Logo doesn’t fully reflect the strength and potential of your business. A fresh, modern logo could make a powerful first impression and help you stand out.
I design bold, timeless identities that truly connect. Want me to take a look?
Check out my work here: https://bit.ly/projects-Anabella
Anabella
Hey there,
I came across your website, and while it looks great, your Logo doesn’t fully reflect the strength and potential of your business. A fresh, modern logo could make a powerful first impression and help you stand out.
I design bold, timeless identities that truly connect. Want me to take a look?
Check out my work here: https://bit.ly/projects-Anabella
Anabella
Hey there,
I came across your website, and while it looks great, your Logo doesn’t fully reflect the strength and potential of your business. A fresh, modern logo could make a powerful first impression and help you stand out.
I design bold, timeless identities that truly connect. Want me to take a look?
Check out my work here: https://rebrand.ly/projects-Anabella
Anabella
Hey there,
I came across your website, and while it looks great, your Logo doesn’t fully reflect the strength and potential of your business. A fresh, modern logo could make a powerful first impression and help you stand out.
I design bold, timeless identities that truly connect. Want me to take a look?
Check out my work here: https://rebrand.ly/projects-Anabella
Anabella
Hey there,
Your site’s solid, but the logo might not be saying enough. A fresh, bold design can help you stand out and connect better with your audience.
I’d love to help want me to take a look?
Check out my work here: https://rebrand.ly/projects-Anabella
Anabella
Hey there,
I came across your website, and while it looks great, it’s not getting the visibility it deserves. With the right SEO strategy, you could attract more of the right visitors and fast.
I help businesses double their targeted traffic in just three months. Want me to take a quick look?
Check out my work here: https://bit.ly/jacob-projects
Jacob
Hey there,
I came across your website the content is great, but the logo doesn’t match the level of what you’re offering. A clean, modern logo makes a big first impression.
I design logos that feel right for your brand. One client said it helped them get more clicks and trust.
Want me to take a quick look?
check out my work here: https://bit.ly/projects-camila
Camila
Hey there,
I came across your website the content is great, but the logo doesn’t match the level of what you’re offering. A clean, modern logo makes a big first impression.
I design logos that feel right for your brand. One client said it helped them get more clicks and trust.
Want me to take a quick look?
check out my work here: https://rebrand.ly/projects-camila
Camila
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