Citation Nr: 0301678 Decision Date: 01/29/03 Archive Date: 02/07/03 DOCKET NO. 01-07 581 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUE Entitlement to service connection for a chronic genitourinary disorder, to include urinary incontinence. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Michael T. Osborne, Associate Counsel INTRODUCTION The veteran had active service from June 1942 to October 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a October 2000 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts (MA), denying the veteran's claim of entitlement to service connection for urinary incontinence (claimed as urinary disorder secondary to kidney stones) (hereinafter, "urinary incontinence"). FINDING OF FACT There is no evidence of a history, diagnosis, or treatment of a chronic genitourinary disorder, to include urinary incontinence, while the veteran was on active service or within 1 year of the veteran's separation from service, and the evidence of record does not suggest a relationship between a current diagnosis of urinary incontinence and the veteran's service. CONCLUSION OF LAW A chronic genitourinary disorder, to include urinary incontinence, was not incurred in or aggravated by service; and a chronic disease manifested by caliculi of the kidney, bladder, or gall bladder may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 1991 & Supp. 2002); 38 C.F.R. § 3.303, 3.307, 3.309 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board observes that recently enacted law (the Veterans Claims Assistance Act of 2000, hereinafter "the VCAA") and its implementing regulations essentially eliminate the requirement that a claimant submit evidence of a well- grounded claim. These regulations provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. 38 U.S.C.A. §§ 5103A, 5107(a) (West Supp. 2002); 38 C.F.R. §§ 3.102, 3.159(c)-(d)) (2002). The VCAA and its implementing regulations also include new notification provisions. Specifically, they require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary, that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. 38 U.S.C.A. § 5103 (West Supp. 2002); 38 C.F.R. § 3.159(b) (2002). The record reflects that VA has made reasonable efforts to notify the veteran of the information and medical evidence necessary to substantiate his claim of entitlement to service connection claim for urinary incontinence. The veteran was issued a statement of the case in April 2001. Further, the RO requested the veteran's assistance in obtaining medical records pertinent to evaluating his claim via letters issued in April 2000 and November 2002. These documents provided the veteran notice of the law and governing regulations (including the implementing regulations noted above) as well as the reasons for the determinations made regarding his claim of entitlement to service connection for urinary incontinence. The record on this claim also shows that VA has made reasonable efforts to obtain relevant records adequately identified by the appellant. VA has obtained the veteran's service and VA medical records and private medical records from Lahey Clinic Medical Center, Burlington, MA (hereinafter, "Lahey Clinic"). Further, a relevant, contemporaneous VA examination (by contract) of the veteran was accomplished in August 2000. The veteran thus has been advised of the evidence necessary to substantiate his claim and evidence relevant to the claim has been properly developed. As such, there is no further action necessary to comply with the provisions of the VCAA or its implementing regulations. Therefore, the veteran will not be prejudiced as a result of the Board deciding this claim. A review of the veteran's service medical records reveals that the veteran's enlistment physical examination in June 1942 found him physically qualified for enlistment and was negative for any genitourinary system problems other than slight phimosis which was not considered disabling. Subsequent physical examination of the veteran at the U.S. Naval Reserve Midshipmen's School in October 1943 found that his Kahn's test was negative and that he was physically qualified for active duty appointment and commission as an ensign in the U.S. Naval Reserve. The veteran's service medical records show several treatments for urinary calculi (or kidney stones) while in service. On physical examination at the Navy Yard Dispensary, Pearl Harbor, Hawaii (HI), on August 19, 1944, the veteran's chief complaint was extreme pain in his left side, and he reported previous pains in this region which had passed over. Physical examination also revealed slight tenderness in the veteran's left costovertebral angle and in his left lower quadrant. The diagnosis was duodenal ulcer (ureteral calculus, left). After being admitted to the U.S. Naval Hospital, Aiea Heights, HI (hereinafter, "Aiea Heights Naval Hospital"), on August 19, 1944, the veteran complained of severe, dull, heavy pain in his left flank which radiated to his symphysis pubis and lasted about 6 hours during which he had two hypodermic injections for pain. The veteran reported that he had had a similar attack three weeks earlier which had lasted only a few hours. Physical examination showed a rugged appearing young adult who appeared slightly pale with normal abdomen and genitalia. There was no blood in the veteran's urine. An intravenous pyelogram revealed a large left ureteral stone which was manipulated by cystoscopy and then passed. The diagnosis was changed to calculus, utereral, left and the veteran was returned to duty in September 1944. On October 24, 1944, the veteran was suddenly seized by severe pain in the left flank which became localized in his left lower quarter with pain also referred to the left testicle. He was seen at the 69th Field Hospital and returned to duty after the administration of morphine. The veteran's pain kept up and he reported to the 7th Division Dispensary where he was given 1/2 gram of morphine and then transferred to U.S.S. Mount Olympus at which time his chief complaint was pain in his left flank and right groin. The veteran reported his earlier attack of pain at Pearl Harbor and that the kidney stone had been passed after manipulation of cystoscopy. A handwritten note on the chart of the veteran's admission to U.S.S. Mount Olympus indicated "2 other attacks," but no further information was provided. Physical examination revealed a well developed young adult who appeared pale, cold, and clammy. There was slight tenderness over the veteran's left kidney and flank. Urinalysis showed a number of red blood cells. A 1/2 gram of morphine was administered, after which the veteran was much relieved. X-rays were taken and showed a fairly large stone about 1/4 - 1/2 inch in the veteran's bladder. Repeat x-rays were taken two days later on October 26, 1944, and revealed a radio-opaque object in the veteran's bladder that was asymptomatic. The veteran was discharged to duty on October 26, 1944, with a note that he was to be referred to a hospital for further treatment at the first opportunity. There was an addendum to this medical report dated October 31, 1944, indicating that the veteran was being transferred for temporary duty and that, since the veteran had had four attacks of ureteral calculi, he should appear before a Board of Medical Survey (hereinafter, "Medical Survey Board") to determine his fitness to remain in service or to perform all of his duties in service. Following the veteran's transfer for temporary duty, he was seen at Administrative Command, Amphibious Forces, U.S. Pacific Fleet, on November 6, 1944, at which time he reported that he had had three attacks of severe pain caused by ureteral calculus. The veteran's reported medical history at the time of this examination included the previous large left ureteral stone which he had passed in August 1944 in Pearl Harbor (as noted above). The veteran reported that he had had a subsequent attack while on board U.S.S. Rixey in early October 1944, at which time another ureteral stone had been passed after cystoscopy, but records of this treatment had been lost in an enemy bombing attack. The veteran's last incidence had occurred while ashore in a forward area on October 10, 1944, at which time he had been evacuated to U.S.S. Mount Olympus for treatment (as noted above). The veteran's medical history noted the previous x-ray which had revealed a fairly large stone that had apparently passed into his urinary bladder and resulted in the veteran being ordered to a rear area for hospitalization. The diagnosis was calculus, urinary. Following readmission to the Aiea Heights Naval Hospital, on November 6, 1944, the veteran's chief complaint was pain in the left side of his abdomen. The veteran's reported medical history noted that he had had three attacks of renal colic beginning with the August 1944 kidney stone which was passed through the left ureter after cytoscopy and also included the kidney stone passed in October 1944. The veteran stated that, soon after he entered the Philippines, he had had a severe attack of colic on October 20, 1944, that had completely disabled him. The veteran reported that he had frequent urination, soreness in his back, and frequent mild cramping pain in the left lumbar spine. Physical examination revealed some tenderness in the veteran's left lumbar region, no masses palpable in the abdomen, and increased muscle tension over the left side of the abdomen. On November 12, 1944, the veteran experienced a severe attack of pain in the left lumbar region, followed by chill and fever. On November 15, 1944, it was noted that the veteran had fever for two days following an attack of pain. A retrograde pyelogram taken on November 17, 1944 showed ureterocele with stone in the lower left ureter and a large stone in the right kidney. On December 1, 1944, the examiner noted that, since the veteran had had several stones and at present had one in the left ureter and one in the right kidney that would require extensive surgery to remove, it was recommended that he be transferred to a hospital on the mainland United States for treatment. Following this report, there is a notation labeled "INSERT" which states that, on December 6, 1944, the Medical Survey Board found the veteran unfit for duty indefinitely and recommended that he be transferred to a U.S. Naval Hospital on the mainland for further treatment and disposition. The veteran was transferred on December 17, 1944, at which time the veteran was received aboard U.S.S. Orizaba with a diagnosis of calculus, urinary bladder. No unusual symptoms developed and no special therapy was given while the veteran was aboard this ship, and he was transferred to the naval hospital nearest to his port of debarkation for further treatment and disposition on December 23, 1944. The veteran was seen at the U.S. Naval Hospital, Fort Eustis, Lee Hall, Virginia, (hereinafter "Fort Eustis Naval Hospital") from January to March 1945. On admission on January 1, 1945, the veteran's chief complaint was pain in his left kidney area, fever, and abdominal pain of frequency. The veteran denied all urinary system complaints or diseases prior to July 1944. The veteran's medical history noted that the first attack of pain over the left kidney had occurred while he had been in transit from Guadalcanal to Guam in July 1944, followed by the severe attack in August 1944 and then the attack in October 1944 while the veteran was in transit to Leyte (both previously noted). The report of medical history noted that the veteran's attacks were all similar, but varying in degree, and that the veteran had received cystoscopy three times which resulted in total relief after the attacks. The medical history report also noted that the veteran had no current complaint except for some frequency. Physical examination revealed a soft and relaxed abdomen with no masses felt, no tenderness, a non-palpable lower spleen and kidneys, and that his genitalia were negative, although there was some tenderness to a jarring blow over the left renal area. Urinalysis was accomplished on January 6, 1945, and showed dense transparency, negative albumin and sugar, trace amounts of occult blood, and few mucus and calcium oxalates. A series of special examinations of the veteran were accomplished while he was hospitalized at Fort Eustis Naval Hospital in January 1945. In the preliminary urologic consultation obtained on January 5, 1945, it was noted that the veteran had occasional pain in his left kidney and recently had had dysuria (or difficulty or pain on urination), frequency of urination, and hematuria (or blood in the urine). The examiner recommended that the veteran be cystoscoped to determine if he was getting adequate drainage from his left kidney and if it was sufficient to await transfer to another hospital. A January 6, 1945, cystoscopy report noted that the cystoscope had passed easily and that the veteran's bladder mucus was inflamed. No bladder stones, diverticula, or growths were seen and no ureterocele was present. A catheter passed a stone lodged at the intramural portion of the veteran's left ureter and a specimen from the veteran's left kidney was cloudy, prompting a kidney culture test. A flat x-ray of the veteran's left kidney culture showed a large calculus in the right renal area and an oval calculus present in the left ureter. X-rays of retrograde pyelogram revealed that the left kidney appeared to be within normal limits and, although the left pelvis and calices appeared slightly enlarged, they were not definitely abnormal and the ureter was open throughout. A small ovoid shadow was noted lying close above the entrance of the left ureter into the bladder and its appearance and location suggested calculus, although definite association with the contrast medium of the ureter was not established. The examiner recommended that the veteran pass the calculus with the aid of ureteral instruments while awaiting orders for transfer, and thereby clear up his left kidney infection. On January 9, 1945, the examiner at Fort Eustis Naval Hospital noted that the veteran was severely colic on his left side and his urine was cloudy. A calculus was seen protruding at the ureteral orifice and, with manipulation, it disappeared up the ureter and was unable to be extracted until the veteran passed it on January 11th, at which time it was analyzed by the hospital laboratory and found to be composed of two calcium oxalates. Progress notes indicate that, on January 18, 1945, the veteran had no urinary symptoms or pain over either kidney. The veteran's urinalysis was negative on January 22nd. On January 26th, the veteran's bladder was normal and catheters passed to each renal pelvis unobstructed. X-rays were obtained on this date which showed a large oblong shadow in the region of the veteran's lower right kidney. A bilateral retrograde pyelogram was done on this date and both pelvis ureters appeared normal. Re-examination of the urinary tract on this date by retrograde pyelography with special reference to the right side showed the right kidney to be within normal limits. The right pelvis calices and ureter were within normal limits of size and contour. An ovoid shadow was noted overlying the upper portion of the lower pole of the right kidney, suggesting the presence of calculus, but no disturbance of pelvis or calices was observed. The examiner reported that this shadow had been noted on the veteran's previous examination, but was not considered at that time to be indicative of calculus. Stereoscopic films were made of the veteran's genitourinary tract on this date and showed a persistence of the shadow previously described as being in the right renal area. The shadow was, however, less distinct at the time that these films were taken and gave no indication of being a renal stone. Gall bladder x-rays were taken on January 27, 1945, and no calculi were demonstrated, so it was concluded that the shadow previously reported in the right renal area appeared to lie outside the gall bladder shadow, as demonstrated by oral cholecystography. Repeat gall bladder x-rays taken on February 3rd showed essentially the same findings. Flat x- rays of the gall bladder and renal area were taken on February 5th, at which time it was noted that this shadow in the veteran's right upper quadrant persisted and did not appear to change its position upon deep inspiration and expiration. Intravenous pyelograms were made on February 7th showing that the veteran's pelvis was normal and the shadow on his right side was extra renal. Surgical consultation was obtained on February 9th, at which time it was determined, in view of the findings that the opaque shadow (previously described) was neither in the gall bladder or the kidney, that the veteran be returned to full duty after a period of convalescent leave. The veteran showed no urinary symptoms of pain over his right kidney. The diagnosis was changed at this time to phimosis, which was treated successfully with circumcision. The veteran's urinalysis was negative on February 13th, and the diagnosis was changed to no disease on February 14, 1945. The veteran was transferred to the U.S. Naval Hospital, Chelsea, MA (hereinafter "Chelsea Naval Hospital"), on March 19, 1945. On physical examination at Chelsea Naval Hospital on March 20th, the veteran had no current chief complaints and reported a medical history that included several attacks between July 1944 and January 1945 of "collicky" pain, chills, and fever due to a left ureteral calculus, and also reported his previous hospitalizations. Physical examination revealed a well-developed male who was not acutely ill and had an essentially negative abdomen with no tenderness, a non-palpable liver and spleen, normal male genitalia and a negative Kahn's test. Physical examination on March 26th revealed that the veteran's kidneys, ureters, and bladder ("KUB") and his urine were all negative. Intravenous pyelogram and the veteran's KUB showed no evidence of calculi or other renal abnormality on the left side. The previously noted shadow on the left side was still present and had the appearance of a calculus. On April 1st, the diagnosis was changed to calculus, ureter, left by reason of a recurrence of this condition. On April 27th, the examiner reviewed the veteran's previous x-rays taken at Fort Eustis Naval Hospital and concluded that the shadow that had been seen (and previously reported) was apparently outside of the urinary tract and did not represent a calculus. The veteran appeared before the Medical Survey Board on May 3, 1945, with a diagnosis of calculus, ureter, left. He was rated as fit for limited duty of six months' probable duration, and was ordered to limited shore duty within the continental United States for a period of six months at which time he would be reevaluated. The Medical Survey Board's report included a detailed summary of the veteran's case history, including the previous complaints and periods of hospitalization noted above. Physical examination of the veteran by the Medical Survey Board was normal. The veteran's Kahn's test and three urinalyses were all negative. The Medical Survey Board noted that an intravenous pyelogram on March 30, 1945, showed both of the veteran's kidneys to be within normal limits and there had been no demonstrable evidence of urinary tract disease or calculi. The veteran was next examined at Chelsea Naval Hospital, on June 3, 1945, with a chief complaint of pain in his right flank of 3 days' duration. It was noted that the veteran had been discharged from Chelsea Naval Hospital one week earlier, but he had returned with complaints of sharp, intermittent, non-radiating right flank pain with nausea and vomiting, and no hematuria or pyuria. The veteran's reported medical history included his past treatments for, and removal of, 2 kidney stones from his left genitourinary tract. Physical examination revealed a well developed, well nourished male in no distress, somewhat obese, no palpable masses or CVA (costovertebral angle) tenderness on the right, normal genitalia, and negative urine and Kahn's test. The diagnosis was gastroenteritis, acute, and the veteran was discharged to duty on June 14, 1945. On June 19, 1945, the veteran submitted a typed letter to the Chief of Naval Personnel requesting permission to take a physical examination in order to receive a promotion from Ensign to Lieutenant (Junior Grade). He stated that he was submitting this request because, although otherwise qualified for promotion, he was not qualified for sea duty at that time. In his letter, the veteran provided a summary of his wartime service, including a detailed explanation of his problems with kidney stones. The veteran stated that during combat on the island of Guam, he was unable to obtain good drinking water or nourishing food, which may have resulted in his later kidney trouble. The veteran noted that he qualified for the requested physical examination because he was able to perform all duties assigned to him at the Public Works Department, First Naval District Headquarters, Boston, MA, he was physically fit for other than sea duty, and he was not under hospital treatment. Although there is no record of a response to this request in the veteran's service medical records, there is a report of physical examination on December 29, 1945, that indicates "Promotion" as its purpose. This report referred to a contemporaneous medical survey of the veteran conducted by the Medical Survey Board (as will be discussed below). The examiners noted in this report that the veteran's genitourinary system was normal and that he was surveyed to full duty with a diagnosis of no disease as of December 27, 1945, and, further, that the veteran was physically fit for temporary promotion to Lieutenant (Junior Grade). The veteran was reevaluated by the Medical Survey Board on December 31, 1945, at which time it was noted that the veteran had had no recurrence of (renal or urinary) symptoms since January 1945 (when he last passed renal calculi). The Medical Survey Board also noted that the veteran's diagnosis as of November 3, 1945, was calculus, ureter, left. According to the Medical Survey Board, the veteran stated that he had been symptom free since January 1945. Physical examination by the Medical Survey Board was entirely negative. Laboratory work was within normal limits and an intravenous pyelogram revealed no calculi, although it showed no change in the extra renal, extra gall bladder shadow of calcium density described in previous physical examinations of the veteran. The Medical Survey Board concluded that the veteran's present condition was fit for full duty and recommended that he be ordered to full duty. On January 2, 1946, the diagnosis was changed from calculus, ureter, left to no disease, and the veteran was discharged to full duty in accordance with the approved medical survey and recommendation on January 7, 1946. Physical examination of the veteran was accomplished at the time of his release from active duty in August 1946. It was noted that the veteran denied all serious illness or injury while on active duty. The veteran's medical history included, among other things, the past diagnoses of calculus, urethral, left on September 2, 1944, and phimosis on March 9, 1945. The veteran's genitourinary system was noted as normal. The veteran's physical examination also was negative for any defects other than external hemorrhoids, and his Kahn's test was negative. The veteran was found physically qualified for release from active duty. On September 16, 1948, the veteran signed a prepared statement regarding his physical status for the purpose of accepting a permanent appointment in the U.S. Naval Reserve. In that statement, the veteran certified that he had been determined to have been physically qualified for release from active duty and that, subsequent to this determination, his physical condition had not changed. A PULHES classification prepared by the Bureau of Naval Personnel in March 1949 classified the veteran as a "3" under the "P" classification and noted ureteral calculi in the diagnosis section of this classification form. No further explanation was provided. A quadrennial physical examination of the veteran accomplished in November 1950 at the U.S. Naval Shipyard Annex, South Boston, MA, noted no defects. In a summary of pertinent and interval history, it was noted that the veteran had passed kidney stones in January 1946, had been asymptomatic since that time, and had been qualified for full duty since January 15, 1946. The veteran was honorably discharged from the U.S. Naval Reserve on December 28, 1954, with a notation that he was not present for physical examination at the time of his discharge. Following the veteran's radical retropubic prostatectomy at the Lahey Clinic in March 1990, it was noted in a hospital discharge summary that the veteran had been admitted to the gastrointestinal service in November 1989 for colonic polyps and complaining of some pelvic pain, urinary frequency, and urgency. His chief complaint at that time was prostate carcinoma, his prostatic specific antigen (PSA) had been elevated, and he underwent trans-rectal ultrasound and biopsy of his prostate, which had been positive for an adenocarcinoma Gleason Grade VIII/X on the right side. A computerized tomography (CT) scan was obtained in November 1989 and showed no pelvic lymphadenopathy, but did show bilateral renal masses and an arteriogram showed these masses to be benign. The discharge summary prepared in March 1990 noted the veteran's medical history of colonic polyps, ureteral calculi, hemorrhoids, and status post-right inguinal hernia repair. Physical examination of the veteran at the Lahey Clinic in March 1990 showed a well developed, well nourished male in no acute distress. The veteran's abdomen was soft and non- tender without hepatosplenomegaly or masses and there was no costovertebral angle tenderness. Genitourinary examination revealed an uncircumcised male with normally descended testicles. Rectal examination revealed a rock hard right lobe of the prostate. The veteran underwent a radical retropubic prostatectomy and pelvic lymph node dissection (discussed below) because, at the time of this operation in March 1990, it was felt that the veteran's tumor probably extended outside the prostatic capsule and probably into the seminal vesicles. Postoperative pathology confirmed that the veteran's lymph nodes were negative, but there was an extensive and diffuse infiltrating Gleason XIII/X adenocarcinoma of the prostate that was extracapsular and as well as invading the seminal vesicles bilaterally. The veteran's urine output remained excellent throughout his postoperative course and, at the time of his discharge, his urine was clear. The veteran was discharged with a Foley catheter in place for removal approximately 10-14 days after surgery. The discharge diagnosis was Stage C adenocarcinoma of the prostate. In the pathology report that accompanied the report of the veteran's radical prostatectomy and lymph node dissection in March 1990, the pathologist noted that a tumor had not been found either in frozen and non-frozen sections of four of the veteran's left obturator lymph nodes or in frozen and non- frozen sections of one of the veteran's right obturator lymph nodes that had been reviewed. An extensive and diffusely infiltrating, poorly differentiated adenocarcinoma of the prostate (Gleason grade 8) was found in the left seminal vesicle and prostate samples reviewed. This tumor extensively invaded the prostatic capsule with periprostatic spread to the soft tissue and the seminal vesicles bilaterally. Vascular invasion was present and there was incidental "senile" amyloidosis of the seminal vesicles. This pathology report included a pre-operative diagnosis of prostatic cancer, but no post-operative diagnosis. The operative report of the veteran's bilateral pelvic lymphadenectomy and radical retropubic prostatectomy in March 1990, noted that the veteran had presented with frequency, dysuria, and painful urination with pelvic discomfort and had been worked up by the gastrointestinal service (as noted above). It was noted that the veteran had a medical history of colonic polyps and hemorrhoids, elevated PSA, and negative results from previously conducted bone and CT scans. It was noted that there were no complications resulting from the surgical procedures performed on the veteran. Finally, the preoperative diagnosis was Stage II Prostate carcinoma and the postoperative diagnosis was probable stage C prostate carcinoma. On May 30, 1990, the veteran was admitted to the Lahey Clinic for a bilateral orchiectomy (or removal of the testes). At that time, the examiner noted that the veteran's PSA had continued to rise and that he had developed constipation with perineal pain. The veteran also had been seen for lumbar stenosis (or narrowing). The examiner noted that the veteran was status post radical retropubic prostatectomy, pathology on the bilateral testis specimen had showed capsular penetration in multiple areas, and the tumor had been high Gleason grade. In view of the veteran's rising PSA, an orchiectomy for hormonal therapy to his prostate was undertaken to help reduce his pain and the veteran tolerated this procedure well. The pre- and post-operative diagnosis was adenocarcinoma of the prostate, stage C. The pathology report that accompanied the report of the veteran's bilateral orchiectomy dated June 1, 1990, also contained a final diagnosis of testicles with mild atrophy. The veteran was seen again at the Lahey Clinic in June 1991 for cystoscopy and an injection of collagen into the bladder neck and urethra. At that time, the veteran complained of persistent stress urinary incontinence. The examiner noted that the veteran had undergone radical retropubic prostatectomy in the past. During the procedure, the surgeon noted that the anterior urethra was normal and there were mild trabeculations to the bladder with normal appearing ureteral orifices. The pre- and post-operative diagnosis was stress urinary incontinence and status post radical retropubic prostatectomy. The veteran returned to the Lahey Clinic in September 1991 for a second injection. The examiner noted that the veteran was 1 1/2 years status post radical retropubic prostatectomy for stage C prostate carcinoma and that the veteran suffered from stress incontinence and was status post injection of collagen into his bladder neck in June 1991. The veteran had returned for a second injection because he had had minimal effects from the first injection. During the procedure, it was noted that cystoscopy of the bladder was normal with normal orifices. The pre- and post-operative diagnosis was status post radical retropubic prostatectomy and stress incontinence. The veteran was next seen at the Lahey Clinic for placement of an artificial urinary sphincter (AUS) in September 1998, the results of which were contained in an operative report and a discharge summary. At that time, the examiner noted in the operative report that the indications for this procedure were, among other things, the veteran's post-prostatectomy incontinence, bilateral orchiectomy, and attempted injections of the bladder neck. The examiner also noted that the injections had not helped the veteran's incontinence and that he currently wore diapers. The pre- and post-operative diagnosis on the operative report was prostate cancer and urinary incontinence. The report indicated that there were no complications from the procedure. The discharge summary that accompanied the operative report for the placement of the veteran's AUS at the Lahey Clinic in September 1998 noted that the veteran's past medical history was significant for bilateral pelvic lymph node dissection with radical retropubic prostatectomy, status post orchiectomy, cystoscopy with collagen implant, and status post cystoscopy injection. Physical examination showed that the veteran was in no acute distress and his abdomen was in no acute distress. Genitourinary examination showed a normal phallus and no testicles. The discharge summary noted that the veteran's urine was clear post-operatively, and that the veteran would have urinary incontinence for six to eight weeks until the AUS was activated. The pre-operative diagnosis was prostate carcinoma with urinary incontinence and the post-operative diagnosis was AMS sphincter placement about the urinary sphincter. An inter-operative consultation was obtained at the Lahey Clinic in March 1999, at which time the veteran presented with an incarcerated left inguinal hernia. The examiner noted that the veteran was status post radical retropubic prostatectomy with radiation therapy and had urinary incontinence with a urinary sphincter in place. According to the examiner, the consultation was necessary because the reservoir for the sphincter had eroded with the hernia into the inguinal canal. After the sphincter was deactivated, the veteran had a Foley catheter placed and the hernia repaired. The examiner's assessment was erosion to the internal canal of the reservoir for the sphincter. The veteran was seen on subsequent occasions for follow-up to the placement of the AUS in May 1999, June 1999, and in February 2000. The examiner noted in May 1999 that the veteran was 10 days status post inguinal hernia repair and insertion of reservoir. A procedure was accomplished whereby a catheter was inserted and the AUS was deactivated. Cystoscopy showed that the sphincter opened. The examiner's plan was to leave the catheter out and the sphincter deactivated. In June 1999, the examiner noted that the veteran had not used the AUS since the earlier hernia repair in March. The examiner noted that the veteran was gaining strength and upper body mobility through physical therapy, but that the veteran wanted to wait until September to reactivate the sphincter. In February 2000, the examiner noted that the veteran had had difficulty controlling the AUS and that it had been left deactivated. Physical examination at that time showed no change appearing in the veteran's external genitalia and that the control device was palpable in his left hemiscrotum. The examiner discussed with the veteran his difficulty controlling the AUS, given his carpal tunnel bilateral hand weakness, and the examiner noted that he would hold off on activating the veteran's AUS. The examiner noted that he would allow the veteran to wear pads to deal with his incontinence. The examiner also noted that, although there was an AUS in place, since his left inguinal hernia repair, the veteran had been unable to use the AUS and that he had been in acute incontinence on two occasions. The veteran's most recent VA examination (a contract examination conducted by QTC Medical Services) was accomplished in August 2000. The examiner noted that the veteran presented at that time for an assessment of his urinary condition and that the veteran's medical records had been reviewed while preparing the examination report. The veteran related a medical history that included the development of a renal calculus in 1944 while in service which, after conservative management failed, was extracted by cystoscopy in 1945. The veteran stated to the examiner that he had had no problem with renal calculi since service. The veteran also reported a medical history that included the 1989 prostate cancer diagnosis, bilateral orchiectomy, prostatectomy, and that he had been incontinent since that time (all noted above). The veteran reported the insertion of a mechanical urinary sphincter in an attempt to control his urinary incontinence (also noted above), but this had been unsuccessful. The examiner noted that the veteran was completely incontinent of urine at the time of this examination, wore an adult diaper all the time, and had developed local dermatitis around his genital area as a result of his incontinence. The veteran reported that he had suffered two recent strokes which required his wife to help with his self care and that he did not exercise regularly due to his debility. The examiner noted that the veteran's medical history included, among other things, a diagnosis of post left inguinal hernia repair. Physical examination in August 2000 revealed that the veteran was well developed and nourished. Examination of the veteran's abdomen revealed that he was anicteric (or not jaundiced) with a midline, suprapubic, and very faint left inguinal well-healed surgical scars, normal bowel sounds, and no superficial venous distention, ascites, masses, organomegaly, or tenderness noted. Genital examination noted general dermatitis in the genital area, an uncircumcised penis with no deformity, and an empty scrotum with absent testicles. Rectal examination revealed no prostatic tissues. The examiner stated that he was unable to perform a urinalysis due to the veteran's being incontinent, although the veteran's complete blood chemistry (CBC) revealed a mild non-specific anemia and some minor abnormalities. The diagnosis was that the veteran suffered from urinary incontinence as a result of the surgical prostatectomy procedure performed for his prostate cancer. According to the examiner, the veteran's current disability was primarily due to his two recent strokes. Based on the medical evidence outlined above, the RO denied the veteran's claim of entitlement to service connection for urinary incontinence (claimed as urinary disorder secondary to kidney stones) in October 2000. In his substantive appeal filed with the RO in August 2001, the veteran stated that, because most of his in-service examinations had been performed without flexible tubes, they had most likely damaged his kidneys and urinary canal. The veteran also stated that, after his radical prostate surgery in 1990, it was determined that spots on his kidneys were not cancer but scar tissue probably from the procedures that had been performed on the veteran while in service. He stated that, if the kidney scarring from his in-service procedures had not appeared, he would not have been in his current position. Service connection may be granted for disability resulting from disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 1991 & Supp. 2002); 38 C.F.R. § 3.303 (2002). A chronic disease will be considered to have been incurred in service when manifested to a degree of 10 percent or more within 1 year from the date of separation from active service. See 38 C.F.R. § 3.307 (2002). Calculi of the kidney, bladder, or gall bladder shall be considered a chronic disease within the meaning of 38 C.F.R. § 3.307. See 38 C.F.R. § 3.309 (2002). Taking into account all of the evidence listed above, the Board finds that the veteran is not entitled to service connection for a chronic genitourinary disorder, to include urinary incontinence. As noted above, a review of the veteran's service medical records demonstrates that all of his well-documented problems with kidney stones (or renal calculi) were resolved successfully following treatment in service. It was noted in January 1945 that the veteran's repeated attacks of pain caused by kidney stones had been treated successfully with cystoscopy which resulted in total relief after each of these attacks. Specifically, although the veteran's service medical records include multiple in- service treatments for renal calculi, the Medical Survey Board concluded in January 1946 that the veteran suffered from no disease. Further, physical examination of the veteran accomplished at the time of his release from active duty in August 1946 was negative for any defects other than external hemorrhoids and physical examination in November 1950 also noted no defects. At no time during the veteran's treatment at the Lahey Clinic, beginning in 1989, for, among other things, prostate cancer and urinary incontinence, was a diagnosis made linking the veteran's current disabilities (including his urinary incontinence) to service. Further, all of the Lahey Clinic examiners who saw the veteran for his recent urinary problems noted the veteran's in-service history of problems stemming from renal calculi and diagnosed conditions other than a link between the veteran's in-service medical problems and post- service disabilities. In fact, there were no complications from the veteran's bilateral pelvic lymphadenectomy and radical retropubic prostatectomy noted immediately following these procedures in March 1990. Most importantly, the veteran's most recent VA examination (by contract) in August 2000 developed specific medical evidence linking his current disability to a series of two strokes and not to any in- service medical problems. The veteran himself admitted to the VA examiner (by contract) that he had had no problem with renal calculi (or kidney stones) since service. Further, the VA examiner (by contract) concluded that the veteran's current urinary incontinence was a result of the veteran's prostate surgery in 1989, which had occurred more than 40 years after his active service. With respect to the veteran's assertion of a link between his well-documented in-service problems with kidney stones and his post-service prostate cancer surgery and resulting urinary incontinence it is pointed out that, as a layman without proper medical training and expertise, the veteran is not competent to provide probative medical evidence on a matter such as the diagnosis or etiology of a claimed medical condition. See Espiritu v. Derwinski, 2 Vet.App. 492, 494-5 (1992). Therefore, the Board cannot assign any probative value to the veteran's lay assertions that his urinary incontinence was incurred in service. In conclusion, the Board notes that it is sympathetic to the veteran's continuing medical problems. However, because the medical evidence of record does not suggest a relationship between the veteran's current urinary incontinence and his active service, the Board denies the veteran's claim of entitlement to service connection for a chronic genitourinary disorder, to include urinary incontinence. As a final point, the Board notes that, although the RO denied this claim as not well grounded, the VCAA has eliminated the well-grounded requirement. However, the Board finds that there is no prejudice to the veteran in the Board considering this claim on the merits in the first instance. See Bernard v. Brown, 4 Vet. App. 384, 394 (1995); 57 Fed. Reg. 49747, VAOGCPREC 16-92 (O.G.C. Prec. 16-92) (1992). As noted above, the duties to notify and assist the veteran in developing the evidence to support the claim has been met, and under either theory, the claim is being denied because, after providing the veteran a QTC examination in August 2000, there still remains a lack of a nexus between any current genitourinary disorder, to include urinary incontinence, and the veteran's active military service. Therefore, given the particular facts of this case, the Board determines that there is no reasonable possibility that any further assistance would aid in substantiating the claim. 38 U.S.C.A. §§ 5103A, 5107(a) (West Supp. 2002). Accordingly, the appeal is denied. ORDER Entitlement to service connection for a chronic genitourinary disorder, to include urinary incontinence, is denied. DEBORAH W. SINGLETON Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.