Turkiye Klinikleri Journal of Health Sciences

.: REVIEW
Multipl Sklerozlu Bireylerde Üriner Semptomlar, Bağırsak Semptomları ve Cinsel İşlev Bozukluğunun Tedavisinde Pelvik Taban Kas Eğitimi: Geleneksel Derleme
Pelvic Floor Muscle Training in the Treatment of Urinary Symptoms, Bowel Symptoms, and Sexual Dysfunction in People with Multiple Sclerosis: Traditional Review
İpek YAVAŞa,b, Özge ERTEKİNc , Turhan KAHRAMANd,e
aDokuz Eylül Üniversitesi Sağlık Bilimleri Enstitüsü, Fizyoterapi ve Rehabilitasyon AD, İzmir, Türkiye
bİzmir Ekonomi Üniversitesi Sağlık Hizmetleri Meslek Yüksekokulu, Fizyoterapi Bölümü, İzmir, Türkiye
cDokuz Eylül Üniversitesi Fizyoterapi ve Rehabilitasyon Fakültesi, Nörolojik Fizyoterapi-Rehabilitasyon Bölümü, İzmir, Türkiye
dİzmir Kâtip Çelebi Üniversitesi Sağlık Bilimleri Fakültesi, Fizyoterapi ve Rehabilitasyon Bölümü, İzmir, Türkiye
eManchester Metropolitan Üniversitesi Sağlık ve Eğitim Fakültesi, Sağlık Meslekleri Bölümü, Manchester, Birleşik Krallık
Turkiye Klinikleri J Health Sci. 2024;9(2):401-8
doi: 10.5336/healthsci.2023-100648
Article Language: TR
Full Text
ÖZET
 Multipl skleroz (MS), santral sinir sisteminin otoimmün kaynaklı nörodejeneratif bir hastalığıdır. MS'li bireyler santral sinir sistemi tutulumuna bağlı çok çeşitli semptomlar yaşayabilmektedir. MS'li bireylerin %80'inden fazlası üriner semptomlar, %39-73'ü bağırsak semptomları ve %40-90'ı cinsel işlev bozukluğu bildirmektedir. Aynı zamanda bu semptomlar MS'li bireyin yaşam kalitesini olumsuz yönde etkileyen bir dizi soruna yol açmaktadır. Bu semptomların tedavisinde kullanılan fizyoterapi yöntemlerinden olan pelvik taban kas eğitimi günümüzde üriner inkontinans, pelvik organ prolapsusu ve fekal inkontinans için öncelikli tercih edilen bir tedavi seçeneğidir ayrıca cinsel işlevi iyileştirmede etkili olabileceğini gösteren çalışmalar bulunmaktadır. Bu derlemenin amacı, MS'li bireylerde pelvik taban kas eğitiminin önemini ve MS'ye bağlı üriner semptomlar, bağırsak semptomları ve cinsel işlev bozukluğunun yönetimindeki yerini vurgulamaktır. MS'li bireylerde pelvik taban kas eğitimi üriner inkontinans, aşırı aktif mesane ve cinsel işlev bozukluğu tedavisinde etkili bir yöntemdir. Ayrıca pelvik taban kas eğitimi alan MS'li bireylerde yaşam kalitesi de artmaktadır. Literatürde biofeedback eğitiminin fekal inkontinans ve konstipasyon için etkili olduğunu gösteren çalışmalar bulunmaktadır. Çalışmalar müdahalelerini pelvik taban kas eğitimi olarak tanımlanmasa da biofeedback eğitimi pelvik taban kas eğitiminde egzersizlerin doğrulanması ve eğitimin gerçekleşmesi amacıyla kullanılan bir yöntemdir bu nedenle de pelvik taban kas eğitiminin fekal inkontinansı ve konstipasyonu tedavi etmede etkili bir yöntem olduğu görülmektedir. MS'li bireylerde üriner retansiyonun tedavi edilmesinde mevcut bir çalışma bulunmasa da ümit vaat eden bir alandır ve araştırılması gerekmektedir. Ayrıca mevcut kanıtların güçlendirilmesi ve net bir tedavi protokolünün tanımlanması için metodolojik olarak kaliteli araştırmalara ihtiyaç vardır.

Anahtar Kelimeler: Multipl skleroz; üriner inkontinans; fekal inkontinans; cinsel işlev bozukluğu; pelvik taban kas eğitimi
ABSTRACT
 Multiple sclerosis (MS) is an autoimmune-based, neurodegenerative disease of central nervous system. People with MS (pwMS) may experience a wide variety of symptoms due to central nervous system involvement. More than 80% of pwMS report urinary symptoms, 39-73% report bowel symptoms, and 40-90% report sexual dysfunction. At the same time, these symptoms lead to a series of problems that negatively affect quality of life of pwMS. Pelvic floor muscle training, one of the physiotherapy methods used in treating these symptoms, is now recommended as first-line treatment option for urinary incontinence, pelvic organ prolapse and fecal incontinence, and there is evidence showing that it may be effective in improving sexual function. This review aims to emphasize importance of pelvic floor muscle training in pwMS and its place in management of MS-related urinary symptoms, bowel symptoms and sexual dysfunction. Pelvic floor muscle training is an effective method in treatment of urinary incontinence, overactive bladder and sexual dysfunction in pwMS. In addition, quality of life increases in pwMS who receive pelvic floor muscle training. Evidence in the literature shows that biofeedback training is effective for fecal incontinence and constipation. Although the studies do not define their interventions as pelvic floor muscle training, biofeedback training is used to verify exercises and realize training in pelvic floor muscle training. Although there is no studies for treating urinary retention in pwMS, it is a promising area that must be investigated. Additionally, methodologically high-quality research is needed to strengthen existing evidence and define a clear treatment protocol.

Keywords: Multiple sclerosis; urinary incontinence; fecal incontinence; sexual dysfunction; pelvic floor muscle training
REFERENCES:
  1. McGinley MP, Goldschmidt CH, Rae-Grant AD. Diagnosis and treatment of multiple sclerosis: a review. JAMA. 2021;325(8):765-79. Erratum in: JAMA. 2021;325(21):2211. [Crossref]  [PubMed] 
  2. Tullman MJ. Overview of the epidemiology, diagnosis, and disease progression associated with multiple sclerosis. Am J Manag Care. 2013;19(2 Suppl):S15-20. [PubMed] 
  3. Compston A, Coles A. Multiple sclerosis. Lancet. 2008;372(9648):1502-17. [Crossref]  [PubMed] 
  4. Preziosi G, Gordon-Dixon A, Emmanuel A. Neurogenic bowel dysfunction in patients with multiple sclerosis: prevalence, impact, and management strategies. Degener Neurol Neuromuscul Dis. 2018;8:79-90. [Crossref]  [PubMed]  [PMC] 
  5. Phé V, Chartier-Kastler E, Panicker JN. Management of neurogenic bladder in patients with multiple sclerosis. Nat Rev Urol. 2016;13(5):275-88. [Crossref]  [PubMed] 
  6. Önol FF, Tahra A. Tanım ve sınıflama. Onur R, Bayrak Ö, editörler. Üriner İnkontinans Tanı ve Tedavi. İstanbul: Türk Üroloji Derneği; 2015. p.63-6. [Link] 
  7. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An international urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29(1):4-20. [Crossref]  [PubMed] 
  8. Al Dandan HB, Coote S, McClurg D. Prevalence of lower urinary tract symptoms in people with multiple sclerosis: a systematic review and meta-analysis. Int J MS Care. 2020;22(2):91-9. [Crossref]  [PubMed]  [PMC] 
  9. de Sèze M, Ruffion A, Denys P, Joseph PA, Perrouin-Verbe B; GENULF. The neurogenic bladder in multiple sclerosis: review of the literature and proposal of management guidelines. Mult Scler. 2007;13(7):915-28. [Crossref]  [PubMed] 
  10. Kim JH. Textbook of the Neurogenic Bladder. 3rd ed. Int Neurourol J. 2015;19(4):295. [Crossref]  [PubMed]  [PMC] 
  11. DasGupta R, Fowler CJ. Bladder, bowel and sexual dysfunction in multiple sclerosis: management strategies. Drugs. 2003;63(2):153-66. [Crossref]  [PubMed] 
  12. Lew-Starowicz M, Rola R. Prevalence of sexual dysfunctions among women with multiple sclerosis. Sex Disabil. 2013;31(2):141-53. [Crossref]  [PubMed]  [PMC] 
  13. Dupont S. Multiple sclerosis and sexual functioning-a review. Clin Rehabil. 1995;9(2):135-41. [Crossref] 
  14. Pöttgen J, Rose A, van de Vis W, Engelbrecht J, Pirard M, Lau S, et al; RiMS Special Interest Group Psychology and Neuropsychology. Sexual dysfunctions in MS in relation to neuropsychiatric aspects and its psychological treatment: a scoping review. PLoS One. 2018;13(2):e0193381. [Crossref]  [PubMed]  [PMC] 
  15. Zecca C, Riccitelli GC, Disanto G, Singh A, Digesu GA, Panicari L, et al. Urinary incontinence in multiple sclerosis: prevalence, severity and impact on patients' quality of life. Eur J Neurol. 2016;23(7):1228-34. [Crossref]  [PubMed] 
  16. Tepavcevic DK, Kostic J, Basuroski ID, Stojsavljevic N, Pekmezovic T, Drulovic J. The impact of sexual dysfunction on the quality of life measured by MSQoL-54 in patients with multiple sclerosis. Mult Scler. 2008;14(8):1131-6. [Crossref]  [PubMed] 
  17. Kisic-Tepavcevic D, Pekmezovic T, Trajkovic G, Stojsavljevic N, Dujmovic I, Mesaros S, et al. Sexual dysfunction in multiple sclerosis: a 6-year follow-up study. J Neurol Sci. 2015;358(1-2):317-23. Erratum in: J Neurol Sci. 2017;372:201. [Crossref]  [PubMed] 
  18. Mota RL. Female urinary incontinence and sexuality. Int Braz J Urol. 2017;43(1):20-8. [Crossref]  [PubMed]  [PMC] 
  19. Cameron AP, Smith AR, Lai HH, Bradley CS, Liu AB, Merion RM, et al; LURN Study Group. Bowel function, sexual function, and symptoms of pelvic organ prolapse in women with and without urinary incontinence. Neurourol Urodyn. 2018;37(8):2586-96. [Crossref]  [PubMed]  [PMC] 
  20. Eickmeyer SM. Anatomy and physiology of the pelvic floor. Phys Med Rehabil Clin N Am. 2017;28(3):455-60. [Crossref]  [PubMed] 
  21. Özakbaş S. Multipl sklerozda semptomatik tedavi [Symptomatic menagement in multiple sclerosis]. Noro Psikiyatr Ars. 2011;48(2):83-9. [Link] 
  22. Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018;10(10):CD005654. [Crossref]  [PubMed]  [PMC] 
  23. Berghmans B, Bols E, Sahlin Y, Berner E. Evidence-based physical therapy for pelvic floor dysfunctions affecting both women and men. In: Bo K, Berghmans B, Morkved S, Van Kampen M, eds. Evidence-Based Physical Therapy for the Pelvic Floor. 2nd ed. Edinburgh: Churchill Livingstone; 2015. p.311-53. [Crossref] 
  24. Park SH, Kang CB. Effect of kegel exercises on the management of female stress urinary incontinence: a systematic review of randomized controlled trials. Adv Nurs. 2014;2014:1-10. [Crossref] 
  25. Rosenbaum TY. Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabilitation in treatment: a literature review. J Sex Med. 2007;4(1):4-13. [Crossref]  [PubMed] 
  26. Ashton-Miller JA, DeLancey JO. Functional anatomy of the female pelvic floor. Ann N Y Acad Sci. 2007;1101:266-96. [Crossref]  [PubMed] 
  27. Lawson S, Sacks A. Pelvic floor physical therapy and women's health promotion. J Midwifery Womens Health. 2018;63(4):410-7. [Crossref]  [PubMed] 
  28. Ghaderi F, Oskouei AE. Physiotherapy for women with stress urinary incontinence: a review article. J Phys Ther Sci. 2014;26(9):1493-9. [Crossref]  [PubMed]  [PMC] 
  29. Pescatori M. Clinical evaluation, etiology, and classification of anal incontinence. In: Docimo L, Brusciano L, eds. Anal Incontinence Clinical Management and Surgical Techniques. Springer Cham; 2023. p.21-8. [Crossref] 
  30. Bo K, Frawley HC, Haylen BT, Abramov Y, Almeida FG, Berghmans B, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction. Neurourol Urodyn. 2017;36(2):221-44. [Crossref]  [PubMed] 
  31. Haslam J. Historical perspective of pelvic floor muscle training. In: Haslam J, Laycock J, eds. Therapeutic Management of Incontinence and Pelvic Pain: Pelvic Organ Disorders. 2nd ed. London: Springer; 2007. p.85-8. [Crossref] 
  32. Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol. 1948;56(2):238-48. [Crossref]  [PubMed] 
  33. Bø K, Talseth T. Long-term effect of pelvic floor muscle exercise 5 years after cessation of organized training. Obstet Gynecol. 1996;87(2):261-5. [Crossref]  [PubMed] 
  34. Coşkun B, Kadıhasanoğlu M. Üriner inkontinansta konservatif tedavi seçenekleri. Onur R, Bayrak Ö, editörler. Üriner İnkontinans Tanı ve Tedavi. İstanbul: Türk Üroloji Derneği; 2015. p.213-21. [Link] 
  35. Bo K, Morkved S. Motor learning. In: Bo K, Berghmans B, Morkved S, Van Kampen M, eds. Evidence-Based Physical Therapy for the Pelvic Floor. 2nd ed. Edinburg: Churchill Livingstone; 2015. p.111-7.
  36. Bo K, Aschehoug A. Strength training. In: Bo K, Berghmans B, Morkved S, Van Kampen M, eds. Evidence-Based Physical Therapy for the Pelvic Floor. 2nd ed. Edinburgh: Churchill Livingstone; 2015. p.117-30.
  37. Yavas I, Emuk Y, Kahraman T. Pelvic floor muscle training on urinary incontinence and sexual function in people with multiple sclerosis: a systematic review. Mult Scler Relat Disord. 2022;58:103538. [Crossref]  [PubMed] 
  38. Kajbafvala M, Ashnagar Z, Lucio A, Firoozeh F, Salehi R, Pashazadeh F, et al. Pelvic floor muscle training in multiple sclerosis patients with lower urinary tract dysfunction: a systematic review and meta-analysis. Mult Scler Relat Disord. 2022;59:103559. [Crossref]  [PubMed] 
  39. Gopal A, Sydow R, Block V, Allen DD. Effectiveness of physical therapy in addressing sexual dysfunction in individuals with multiple sclerosis: a systematic review and meta-analysis. Int J MS Care. 2021;23(5):213-22. [Crossref]  [PubMed]  [PMC] 
  40. Yavas I, Kahraman T, Sagici O, Ozdogar AT, Yigit P, Baba C, et al. Feasibility of telerehabilitation-based pelvic floor muscle training for urinary incontinence in people with multiple sclerosis: a randomized, controlled, assessor-blinded study. J Neurol Phys Ther. 2023;47(4):217-26. [Crossref]  [PubMed] 
  41. Bulbul SB, Keser I, Yucesan C, Celenay ST. Effects of pelvic floor muscle training applied with telerehabilitation in patients with multiple sclerosis having lower urinary track symptoms: A randomized controlled trial. Health Care Women Int. 2023:1-17. [Crossref]  [PubMed] 
  42. McClurg D, Ashe RG, Marshall K, Lowe-Strong AS. Comparison of pelvic floor muscle training, electromyography biofeedback, and neuromuscular electrical stimulation for bladder dysfunction in people with multiple sclerosis: a randomized pilot study. Neurourol Urodyn. 2006;25(4):337-48. [Crossref]  [PubMed] 
  43. Lúcio AC, Campos RM, Perissinotto MC, Miyaoka R, Damasceno BP, D'ancona CA. Pelvic floor muscle training in the treatment of lower urinary tract dysfunction in women with multiple sclerosis. Neurourol Urodyn. 2010;29(8):1410-3. [Crossref]  [PubMed] 
  44. Yazdian M, Nazari S. Assessment of climate change parameters impact on long-term sediment transport trend case study: Azam River basin. International Journal of Hydrology Science and Technology. 2020;10(2):191. [Crossref] 
  45. Ferreira AP, Pegorare AB, Salgado PR, Casafus FS, Christofoletti G. Impact of a pelvic floor training program among women with multiple sclerosis: a controlled clinical trial. Am J Phys Med Rehabil. 2016;95(1):1-8. [Crossref]  [PubMed] 
  46. Silva Ferreira AP, de Souza Pegorare ABG, Miotto Junior A, Salgado PR, Medola FO, Christofoletti G. A controlled clinical trial on the effects of exercise on lower urinary tract symptoms in women with multiple sclerosis. Am J Phys Med Rehabil. 2019;98(9):777-82. [Crossref]  [PubMed] 
  47. Wang AC, Chih SY, Chen MC. Comparison of electric stimulation and oxybutynin chloride in management of overactive bladder with special reference to urinary urgency: a randomized placebo-controlled trial. Urology. 2006;68(5):999-1004. [Crossref]  [PubMed] 
  48. Wang AC, Wang YY, Chen MC. Single-blind, randomized trial of pelvic floor muscle training, biofeedback-assisted pelvic floor muscle training, and electrical stimulation in the management of overactive bladder. Urology. 2004;63(1):61-6. [Crossref]  [PubMed] 
  49. Pérez DC, Chao CW, Jiménez LL, Fernández IM, de la Llave Rincón AI. Pelvic floor muscle training adapted for urinary incontinence in multiple sclerosis: a randomized clinical trial. Int Urogynecol J. 2020;31(2):267-75. [Crossref]  [PubMed] 
  50. Zong J, You M, Li C. Effect of Kegel pelvic floor muscle exercise combined with clean intermittent self-catheterization on urinary retention after radical hysterectomy for cervical cancer. Pak J Med Sci. 2022;38(3Part-I):462-8. [Crossref]  [PubMed]  [PMC] 
  51. Lazaros T, Ioannis T, Vasileios S, Christina P, Michael S. The effect of pelvic floor muscle training in women with functional bladder outlet obstruction. Arch Gynecol Obstet. 2023;307(5):1489-94. [Crossref]  [PubMed]  [PMC] 
  52. Marinkovic SP, Gillen LM. Sacral neuromodulation for multiple sclerosis patients with urinary retention and clean intermittent catheterization. Int Urogynecol J. 2010;21(2):223-8. [Crossref]  [PubMed] 
  53. Minardi D, Muzzonigro G. Sacral neuromodulation in patients with multiple sclerosis. World J Urol. 2012;30(1):123-8. [Crossref]  [PubMed] 
  54. Singleton C, Bakheit AM, Peace C. The efficacy of functional electrical stimulation of the abdominal muscles in the treatment of chronic constipation in patients with multiple sclerosis: a pilot study. Mult Scler Int. 2016;2016:4860315. [Crossref]  [PubMed]  [PMC] 
  55. Sajadi M, Davodabady F, Naseri-Salahshour V, Harorani M, Ebrahimi-Monfared M. The effect of foot reflexology on constipation and quality of life in patients with multiple sclerosis. A randomized controlled trial. Complement Ther Med. 2020;48:102270. Erratum in: Complement Ther Med. 2020;49:102330. [Crossref]  [PubMed] 
  56. McClurg D, Hagen S, Hawkins S, Lowe-Strong A. Abdominal massage for the alleviation of constipation symptoms in people with multiple sclerosis: a randomized controlled feasibility study. Mult Scler. 2011;17(2):223-33. [Crossref]  [PubMed] 
  57. Preziosi G, Raptis DA, Storrie J, Raeburn A, Fowler CJ, Emmanuel A. Bowel biofeedback treatment in patients with multiple sclerosis and bowel symptoms. Dis Colon Rectum. 2011;54(9):1114-21. [Crossref]  [PubMed] 
  58. Munteis E, Andreu M, Martinez-Rodriguez J, Ois A, Bory F, Roquer J. Manometric correlations of anorectal dysfunction and biofeedback outcome in patients with multiple sclerosis. Mult Scler. 2008;14(2):237-42. [Crossref]  [PubMed] 
  59. Wiesel PH, Norton C, Roy AJ, Storrie JB, Bowers J, Kamm MA. Gut focused behavioural treatment (biofeedback) for constipation and faecal incontinence in multiple sclerosis. J Neurol Neurosurg Psychiatry. 2000;69(2):240-3. [Crossref]  [PubMed]  [PMC] 
  60. Thys E, Sasse K. Sacral neuromodulation therapy for urinary and fecal incontinence in patients with multiple sclerosis: report of 6 cases and literature review. Int J MS Care. 2023;25(4):163-7. [Crossref]  [PubMed]  [PMC] 
  61. Mosalanejad F, Afrasiabifar A, Zoladl M. Investigating the combined effect of pelvic floor muscle exercise and mindfulness on sexual function in women with multiple sclerosis: a randomized controlled trial. Clin Rehabil. 2018;32(10):1340-7. [Crossref]  [PubMed] 
  62. Lúcio AC, D'Ancona CA, Lopes MH, Perissinotto MC, Damasceno BP. The effect of pelvic floor muscle training alone or in combination with electrostimulation in the treatment of sexual dysfunction in women with multiple sclerosis. Mult Scler. 2014;20(13):1761-8. [Crossref]  [PubMed] 
  63. Polat Dunya C, Tülek Z, Kürtüncü M, Gündüz T, Panicker JN, Eraksoy M. Evaluating the effects of transcutaneous tibial nerve stimulation or pelvic floor muscle training on sexual dysfunction in female multiple sclerosis patients reporting overactive bladder. Neurourol Urodyn. 2021;40(6):1661-9. [Crossref]  [PubMed] 
  64. Ferreira CH, Dwyer PL, Davidson M, De Souza A, Ugarte JA, Frawley HC. Does pelvic floor muscle training improve female sexual function? A systematic review. Int Urogynecol J. 2015;26(12):1735-50. [Crossref]  [PubMed] 

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4.5. "USER"s accept and undertake that the information and context they provided to the "SITE" are accurate and legal. "Turkiye Klinikleri" is not liable and responsible for promising and guaranteeing the verification of the information and context transmitted to "Turkiye Klinikleri" by the "USER"s, or uploaded, changed and provided through the "SITE" by them and whether these information are safe, accurate and legal.

4.6. "USER"s agree and undertake that they will not perform any action leading to unfair competition, weakening the personal and commercial credit of "Turkiye Klinikleri" and a third party,  encroaching and attacking on personal rights within the "SITE" in accordance with the Turkish Commercial Code Law.

4.7. "Turkiye Klinikleri" reserves the right to change the services and the context within the "SITE"  anytime. "Turkiye Klinikleri" may use this right without any notification and timelessly. "USER"s have to make the changes and/or corrections "Turkiye Klinikleri" required immediately. Any changes and/or corrections that are required by "Turkiye Klinikleri", may be made by "Turkiye Klinikleri" when needed. Any harm, criminal and civil liability resulted or will result from changes and/or corrections required by "Turkiye Klinikleri" and were not made on time by the "USER"s belongs completely to the users.

4.8. "Turkiye Klinikleri" may give links through the "SITE" to other websites and/or "CONTEXT"s and/or folders that are outside of their control and owned and run by third parties. These links are provided for ease of reference only and do not hold qualification for support the respective web SITE or the admin or declaration or guarantee for the information inside. "Turkiye Klinikleri" does not hold any responsibility over the web-sites connected through the links on the "SITE", folders and context, the services or products on the websites provided through these links or their context.

4.9. "Turkiye Klinikleri" may use the information provided to them by the "USERS" through the "SITE" in line with the terms of the "PRIVACY POLICY" and "USER CONTRACT". It may process the information or classify and save them on a database. "Turkiye Klinikleri" may also use the USER's or visitor's identity, address, e-mail address, phone number, IP number, which sections of the "SITE" they visited, domain type, browser type, date and time information to provide statistical evaluation and customized services.

5. PROPRIETARY RIGHTS

5.1. The information accessed through this "SITE" or provided by the users legally and all the elements (including but not limited to design, text, image, html code and other codes) of the "SITE" (all of them will be called as studies tied to "Turkiye Klinikleri"s copyrights) belongs to "Turkiye Klinikleri". Users do not have the right to resell, process, share, distribute, display or give someone permission to access or to use the "Turkiye Klinikleri" services, "Turkiye Klinikleri" information and the products under copyright protection by "Turkiye Klinikleri". Within hereby "Terms of Use" unless explicitly permitted by "Turkiye Klinikleri" nobody can reproduce, process, distribute or produce or prepare any study from those under "Turkiye Klinikleri" copyright protection.

5.2. Within hereby "Terms of Use", "Turkiye Klinikleri" reserves the rights for "Turkiye Klinikleri" services, "Turkiye Klinikleri" information, the products associated with "Turkiye Klinikleri" copyrights, "Turkiye Klinikleri" trademarks, "Turkiye Klinikleri" trade looks or its all rights for other entity and information it has through this website unless it is explicitly authorized by "Turkiye Klinikleri".

6. CHANGES IN THE TERMS OF USE

"Turkiye Klinikleri" in its sole discretion may change the hereby "Terms of Use" anytime announcing within the "SITE". The changed terms of the hereby "Terms of Use" will become valid when they are announced. Hereby "Terms of Use" cannot be changed by unilateral declarations of users.

7. FORCE MAJEURE

"Turkiye Klinikleri" is not responsible for executing late or never of this hereby "Terms of Use", privacy policy and "USER Contract" in any situation legally taken into account as force majeure. Being late or failure of performance or non-defaulting of this and similar cases like this will not be the case from the viewpoint of "Turkiye Klinikleri", and "Turkiye Klinikleri" will not have any damage liability for these situations. "Force majeure" term will be regarded as outside of the concerned party's reasonable control and any situation that "Turkiye Klinikleri" cannot prevent even though it shows due diligence. Also, force majeure situations include but not limited to natural disasters, rebellion, war, strike, communication problems, infrastructure and internet failure, power cut and bad weather conditions.

8. LAW AND AUTHORISATION TO FOLLOW

Turkish Law will be applied in practicing, interpreting the hereby "Terms of Use" and managing the emerging legal relationships within this "Terms of Use" in case of finding element of foreignness, except for the rules of Turkish conflict of laws. Ankara Courts and Enforcement Offices are entitled in any controversy happened or may happen due to hereby contract.

9. CLOSING AND AGREEMENT

Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com