Citation Nr: 0318631 Decision Date: 08/01/03 Archive Date: 08/13/03 DOCKET NO. 98-01 261 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to a compensable rating for left ureteral calculus. 2. Entitlement to a higher initial rating for prostate cancer rated 100 percent disabling prior to February 1, 1998, and noncompensable since that time. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Fetty, Counsel INTRODUCTION The veteran had active service from April 1953 to March 1957 and from June 1957 to September 1972. This appeal arises from a November 1997 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, that continued a noncompensable rating for service connected left ureteral calculus (kidney stones) and reduced the evaluation of service-connected residuals of prostate cancer to noncompensable, effective February 1, 1998. The veteran has appealed to the Board of Veterans' Appeals (Board) for favorable resolution. In June 2000, the Board remanded the case to the RO for additional development. In June 1998, the veteran testified before an RO hearing officer. In December 1999, the veteran testified before a member of the Board who is no longer with the Board. In May 2003, the Board offered the veteran another hearing, however, the veteran did not respond to the offer. The Board therefore assumes that the veteran does not desire another hearing. The medical evidence of record tends to link the veteran's end stage renal disease and subsequent kidney transplant to service-connected diabetes mellitus. The RO should therefore consider secondary service connection for end-stage renal disease and kidney transplant. Other symptoms that have not yet received consideration for secondary service connection have also been attributed to residuals of prostate cancer. A February 2000 private medical report notes that irritable bowel syndrome is probably related to radiation prostatitis. Moreover, that report notes that the drug used to combat the veteran's irritable bowel syndrome causes dry-mouth symptoms, and the veteran has reported such symptoms. The Board therefore refers end-state renal disease and kidney transplant, irritable bowel syndrome, and dry-mouth symptoms to the RO for further consideration for secondary service connection. FINDINGS OF FACT 1. Service-connected ureteral calculus has been manifested throughout the appeal period by recurrent stone formation and a need for diet and drug therapy. 2. Service-connected prostate cancer was eradicated in December 1996 and has not returned since that time. 3. No need for absorbent material has been demonstrated at any time since February 1, 1998. 4. The veteran's urinary frequency is manifested by a need to urinate every two to three hours during daytime and to arise at night up to two times. 5. Voiding obstruction is manifested by dysuria (painful or difficult urination), peak flow rate of 8 cc/sec, and post- void residuals of 100 cc; urinary catheterization is not required. 6. The veteran's urinary tract infections have been manifested by recurring infection requiring continuous intensive management. CONCLUSIONS OF LAW 1. The criteria for a 30 percent schedular rating for ureteral calculus are met throughout the appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.115, 4.115a, 4.115(b), Diagnostic Codes 7509, 7510 (2002). 2. The criteria for a 30 percent schedular rating for residuals of prostate cancer have been met since February 1, 1998. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.115, 4.115a, 4.115(b) (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran's service medical records (SMRs) reflect that he passed a kidney stone in August 1972. In May 1973, the RO granted service connection for left ureteral calculus and assigned a noncompensable rating under Diagnostic Code 7510. In May 1996, the veteran requested an increased rating for ureteral calculus, reporting that the disability had worsened. He reported treatment at Dorn VA Medical Center, the Greenville VA outpatient clinic, and at Anderson Area Medical Center (hereinafter AAMC). In June 1996, the veteran requested service connection for prostate cancer, diabetes, kidney problems, hypertension, and gout. He also requested non-service-connected pension and aid and attendance benefits. In September 1996, the RO continued a noncompensable rating for ureteral calculus, granted special monthly pension at the housebound rate but not the aid and attendance rate, and denied payment of pension due to excessive income. The veteran submitted a notice of disagreement to the rating assigned for his "urinary tract condition". In October 1996, the RO issued a statement of the case (SOC). The claims file does not reflect that the veteran filed a VA Form 9, Substantive Appeal, or other correspondence containing the necessary information, and the RO closed the case. In October 1996, the RO received additional private medical reports from AAMC that reflect that prostate adenocarcinoma was found in May 1996. In February 1997, the RO established service connection for prostate cancer. A 100 percent rating was assigned under Diagnostic Code 7528. According to a March 1997 VA compensation and pension examination report, the veteran's radiation treatments for prostate cancer ended in December 1996. The examiner noted that the veteran was on dialysis for end-stage renal disease and because of dialysis, urinary frequency or other voiding symptoms could not be assessed. In April 1997, a 100 percent rating for prostate cancer was continued. An August 1997 VA compensation and pension examination report reflects that dialysis continued. The veteran reported urinary urgency and reported that he urinated a small amount twice per day. He had no dysuria, history of urinary tract infection, lethargy, weakness, anorexia, weight gain or loss, or incontinence. He did not require catheterization. His food diet was for diabetes mellitus. He did report impotence and he had no morning tumescence, but these conditions predated his prostate cancer. The final diagnosis was prostate cancer without evidence of metastasis. In September 1997, the RO issued a rating decision that proposed to reduce the rating for prostate cancer to noncompensable. The veteran submitted an NOD in October 1997. In October 1997, the veteran also filed a claim for an increased rating for urinary tract disability. He reported that he was on dialysis three times per week. In November 1997, the RO obtained additional VA outpatient treatment reports. A September 1997 report notes that an itching sensation might be due to chemotherapy. An October 1997 report notes symptoms of urgency and bladder fullness and perianal itching due to hemorrhoid treatment. The assessments included minor urinary tract infection. In November 1997, the RO reduced the rating for residuals of prostate cancer to noncompensable effective from February 1, 1998, and continued a noncompensable rating for ureteral calculus. In December 1997, Dr. Malik, radiation oncologist, reported that the veteran completed radiation therapy in December 1996 and had not had a recurrence of prostate cancer. In December 1997, the veteran submitted an NOD to the decision that denied an increased rating for his "kidney condition". The RO issued an SOC addressing both the prostate cancer rating and the ureteral calculus rating in January 1998. In January 1998, the veteran filed a VA Form 9. In June 1998, the veteran testified that he had residual leg weakness from his cancer treatment as well as hot sensations in his groin area when sitting and shortness of breath on exertion. He felt that although his cancer was in remission, he still had cancer. He testified that he took no medication for cancer currently. He testified that his diet caused constipation. He testified that he had no incontinence. He said that he drank cranberry juice as directed to avoid kidney stones and to aid in dialysis and he took calcium Actifed(r) to prevent stones. He recalled that his most recent stone passed about a year and a half earlier. He testified that he urinated infrequently, but he added that his clothing stained frequently because of urine leakage. He felt that his cancer treatment had reduced his sex life. He testified that the service-connected disorders did not affect his employment because employment was precluded by his need for dialysis. He repeated that he followed a special food diet to avoid stones. Following the hearing, the veteran's representative submitted a written claim for service connection for impotence, secondary to service-connected prostate cancer treatment. In an August 1998 rating decision, the RO continued the noncompensable ratings for ureteral calculus and for residuals of prostate cancer. In an October 1998 rating decision, the RO denied special monthly compensation for loss of a creative organ on the basis that no medical evidence linked erectile dysfunction to prostate cancer or treatment. In December 1999, the veteran testified before a former member of the Board that burning sensation on urination began at the time of radiation therapy for prostate cancer. He testified that a Dr. Seiler at AAMC felt that these symptoms might be related to cancer treatment. He mentioned that he had bowel and bladder incontinence that might be related to cancer treatment. During the hearing, the veteran's representative argued that the examination on which the rating reduction was based was inadequate for rating reduction purposes, citing 38 C.F.R. § 3.344(a). The representative added that the veteran had no argument related to ureteral calculus symptoms. In March 2000, R. Kirk Seiler, M.D., wrote a letter to the Board regarding the veteran's urologic problems. Dr. Seiler had reviewed the veteran's cancer history and noted that the veteran received a transplanted kidney in May 1999. Dr. Seiler noted that radiation proctitis still bothered the veteran, as well as "urinary incontinence and dysuria, which may well be related to external beam radiotherapy, although the prostatism from a combination of benign enlargement of the prostate or cancer are also possible etiologies". Dr. Seiler opined that prostate and urinary tract infections could cause irritating voiding symptoms, which, the doctor felt, had become difficult to control, with multiple medications now required and surgery to reopen the prostate channel contemplated should the need arise. In June 2000, the Board remanded the case for additional development, including an examination for ureteral calculus and prostate cancer, and a medical opinion addressing whether the symptoms alleged by the veteran are attributable to the disabilities at issue. The veteran subsequently submitted release forms in favor of all private medical sources identified. The RO subsequently obtained private medical records that reflect continued treatment and dialysis at various times. An April 1999 dialysis report reflects complaint of burning in the suprapubic and retroscrotal areas. The veteran made urine three times per day and complained of slow stream and scrotal knots. Examination revealed some scrotal wall cysts and a tender prostate gland. The impression was probable acute prostatitis. A May 1999 report notes persistent pyuria. A December 1999 report notes a kidney transplant in May 1999 and large amounts of urine production since then. The examiner felt the veteran had moderate to severe voiding symptoms. Another December 1999 report notes that uroflowmetry study showed obstructive voiding symptoms with urinary frequency as well. Maximum flow rate was 8 cc/sec with a mean flow rate of 4 cc/sec and 100 cc of residual urine on one check. 118 cc was voided. A transurethral resection was discussed with the veteran. A February 2000 private medical report reflects complaint of urinary incontinence and urgency. The veteran was taking Cardura(r), 8 mg, for bladder outlet obstructive symptoms. The report notes that the veteran had had prostate cancer, but his PSA (prostatic-specific antigen) level was good. The report also notes that he had some microscopic hematuria and pyuria with known stone disease in his new kidney. The examiner also noted that the veteran had irritable bowel syndrome, probably related to radiation proctitis, for which Levbid(r) was prescribed with the further warning that this drug can lead to dry-mouth. The veteran was warned of the possibility of increased risk of incontinence given his exposure to radiation to the prostate. By March 2000, the veteran was complaining of dry-mouth while reporting that his irritable bowel syndrome and urinary urgency had improved. He was voiding satisfactorily. He had no leakage during a 2-hour visit at Urology Associates, Inc, in March 2000. In May 2000, he complained that his urinary urgency had worsened and he reported fecal soiling, but he reported good urinary stream. In September 2000, Dr. Ralph Henry of AAMC supplied additional private medical reports. An August 1999 report notes that the veteran required a lymphocele catheter for drainage after complications from renal transplant. The catheter exited directly from the area of the kidney transplant. In September 2000, Dr. Malik reported that the veteran had undergone radiation treatment for prostate cancer in October 1996 and had been re-examined in April 2000, at which time PSA was within normal limits and his examination was unremarkable. In October 2000, the veteran underwent a VA genitourinary compensation and pension examination. The examiner reviewed the claims file. The veteran reported that he most recently passed a kidney stone in 1977. He reportedly urinated every two to three hours and arose up to two times during the night to urinate. He denied hesitancy of stream but he did have dysuria. The examiner noted that the veteran was incontinent of bowel and bladder, but did not wear any absorbent material. He was unable to achieve an erection. Physical examination did not reveal any significant abnormalities. The prostate was not enlarged. The relevant impressions were status post kidney transplant, nephrolithiasis, urinary and bowel incontinence, dysuria, diabetes mellitus, impotence, and proteinuria. In February 2002, the veteran underwent another VA compensation and pension examination. The examiner noted a review of the claims file and several questions that were to be addressed. With respect to whether the veteran had recurrent stone formation requiring therapy or treatment or invasive or noninvasive procedure more than two time per year, the examiner reported that the veteran had kidney stones on the left in 1991 and still had a stone on the left side. With respect to whether the veteran currently had colic, the examiner reported that the veteran did not have colicky pain or hematuria. The examiner noted that both kidneys were currently non-functional and that they had been damaged by diabetes mellitus, not a stone. The veteran reported urinary incontinence, but the examiner noted that the veteran did not wear absorbent material and he did not wet the bed. The examiner noted that the veteran took a medication to harden his stools and simultaneously took another medication to soften his stools. The veteran did not appear to need a diaper and his clothing was not soiled at the time of the examination, according to the examiner. The examiner felt that the veteran did not have lethargy, anorexia, or weight loss. Rather, he had gained weight. The examiner felt that the veteran did not have any urinary tract infection or acute nephritis, nor did he require catheterization, frequent dilation, or drainage procedure. The examiner listed 14 current medications, including calcium. The examiner reported that the prostate gland was absent and there was no leakage of stool, no bleeding, and no hemorrhoids. The relevant diagnoses were hypertension, type- 2 diabetes mellitus, chronic renal insufficiency status post dialysis, status post kidney transplant and functioning new kidney, and status post renal stones. The examiner reported that no diet or drug therapy or invasive procedure was required for renal stone. The examiner explained that the veteran currently had one tiny stone sitting in the kidneys, which were not functioning at the moment. The examiner felt that renal disease was secondary to diabetes mellitus, not to stones. The examiner repeated that the veteran had no current voiding problem or incontinence and he did not use a diaper. The examiner felt that there were no current residuals of radiation treatment. In April 2002, the RO issued a supplemental statement of the case (SSOC) discussing the evidence and the noncompensable ratings assigned for ureteral calculus and for prostate cancer. The SSOC also contained the pertinent parts of the Veterans Claims Assistance Act of 2000 (VCAA). In a February 2003 rating decision, the RO established service connection for diabetes mellitus secondary to herbicide exposure and assigned a 20 percent rating under Diagnostic Code 7913. In that rating decision, the RO also assigned an earlier effective date of June 5, 1996, for a 100 percent rating for prostate cancer. II. VCAA During the pendency of this appeal, the VCAA was signed into law. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326) (2002). The VCAA and the implementing regulations are liberalizing and are therefore applicable to the issues on appeal. See Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). The VCAA and the implementing regulations essentially eliminate the requirement that a claimant submit evidence of a well-grounded claim, and 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. The VCAA requires 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 (i.e., to VA) that is necessary to substantiate the claim. 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. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). There is an indication in the record that the veteran has been treated by Drs. Seiler, Malik, Henry, and at the Greenville, South Carolina, and Columbia, South Carolina, VA Medical Centers. All available treatment records from these providers and facilities have been obtained to the extent possible. In Karnas, supra, the United States Court of Appeals for Veterans Claims (hereinafter referred to as the Court) held that where a law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to the veteran should and will apply unless Congress provides otherwise or permits the Secretary to do otherwise. The Court has also held that where a Board decision addresses a question that had not been addressed by the RO, it must consider whether the claimant has been given adequate notice of the need to submit evidence or argument on that question and an opportunity to submit such evidence and argument and to address that question at a hearing, and, if not, whether the claimant has been prejudiced thereby. Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). The Board finds that the veteran is not prejudiced by its consideration of these claims pursuant to this new legislation and implementing regulations insofar as VA has already met all notice and duty to assist obligations under the new law, to include as delineated under the newly promulgated implementing regulations. The veteran has been notified as to the laws and regulations governing the evaluation of ureteral calculus and residuals of prostate cancer. He has been advised of the evidence considered in connection with his claims, and what evidence that is potentially probative or not probative of the claims. 38 C.F.R. § 3.159(b)(1), (e). The RO has attempted to obtain, and has associated with the claims file, all pertinent service records, VA medical records, and the private medical records identified by the claimant. The Board emphasizes that by letters dated in April 2001 and September 2001, the RO notified the veteran of the provisions of the VCAA and its potential impact on his claims, allowing him an additional period of time in which to present evidence and/or argument in support of the appeal. In February 2002, the veteran responded to those letters. III. Legal Analysis Disability evaluations are determined by comparing present symptomatology with the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2002). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is reviewed when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. The regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). VA regulations also require that disability evaluations be based upon the most complete evaluation of the condition that can be feasibly constructed with interpretation of examination reports, in light of the whole history, so as to reflect all elements of disability. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. Functional impairment is based on lack of usefulness and may be due to pain, supported by adequate pathology and evidenced by visible behavior during motion. A. Ureteral Calculi During the appeal period, service-connected ureteral calculi has remained noncompensably rated. Under 38 C.F.R. § 4.115(b), Diagnostic Code 7510, ureterolithiasis (ureteral calculi) is usually rated as hydronephrosis under Diagnostic Code 7509; however, where there is recurrent stone formation requiring diet therapy; drug therapy; or, invasive or noninvasive procedures more than two times per year, a 30 percent rating is warranted under Diagnostic Code 7510. 38 C.F.R. § 4.115(b), Diagnostic Code 7510 (2002). Under Diagnostic Code 7509, hydronephrosis (obstruction of the ureter causing distension of the pelvis and calices of the kidney, Dorland's Illustrated Medical Dictionary 785 (28th ed. 1994)), warrants a 10 percent rating for an occasional attack of colic not requiring catheter drainage. A 20 percent evaluation requires frequent attacks of colic requiring catheter drainage. A 30 percent rating is offered for frequent attacks of colic with infection (pyonephrosis) or other kidney impairment. 38 C.F.R. § 4.115b, Diagnostic Code 7509 (2002). Also under Diagnostic Code 7509, where hydronephrosis is shown to be severe, it must be rated as "renal dysfunction" under the general formula for rating genitourinary system dysfunction where ratings as high as 100 percent are offered. 38 C.F.R. § 4.115a, (2002). Severe hydronephrosis will be further discussed below. In rating the service-connected ureteral calculi, the first issue to be resolved is whether there is evidence of recurrent stone formation requiring one or more of the following: diet therapy; drug therapy; or, invasive or noninvasive procedures more than two times per year. The evidence reflects that the veteran passed a stone in 1972. In October 2000, a VA compensation and pension examiner noted recurrent stone formation, with the most recent occurrence in 1977. The examiner gave an impression of nephrolithiasis. "Nephrolithiasis" is a condition marked by renal calculi, Dorland's Illustrated Medical Dictionary 1109 (28th ed. 1994). Thus, the October 2000 examination report suggests recurrent stone formation since active service. Secondly, in February 2002, another VA compensation and pension examiner mentioned a 1991 stone and added that the veteran still had a small stone in the left kidney. Therefore, the medical evidence clearly reflects evidence of recurrent stone formation. Because there is evidence of recurrent stone formation, the Board must next address whether the condition requires one or more of the following: diet therapy; drug therapy; or, invasive or noninvasive procedures more than two times per year. The veteran testified in June 1998 that he took calcium Actifed(r) and cranberry juice to prevent stones. Calcium is listed in the February 2002 VA examination report as being among the veteran's medications and the Board notes that calcium loading is a preventative measure for recurrent urinary calculi. Moreover, drinking cranberry juice might be construed to be diet therapy. Thus, even though the February 2002 VA examiner stated that diet or drug therapy was not necessary to control stones, the Board finds satisfactory evidence of a history of diet and drug therapies for a recurrent stone formation. Overall, it appears that the service-connected ureteral calculus is manifested by recurrent stone formation and a need for diet and drug therapy. The criteria for a 30 percent rating under Diagnostic Code 7510 are therefore met. As noted above, under Diagnostic Code 7509, where hydronephrosis is shown to be severe, it must be rated as "renal dysfunction" under the general formula for rating genitourinary system dysfunction where ratings as high as 100 percent are offered. In this case, hydronephrosis has not been shown to be severe. Although the veteran certainly has end stage renal disease requiring regular dialysis, this is not due to hydronephrosis, but rather has been attributed to diabetes. Thus, the criteria for a rating higher than 30 percent under any applicable diagnostic code are not more nearly approximated. After consideration of all of the evidence of record, including the testimony, the Board finds that the evidence favors a 30 percent rating for ureteral calculi for the entire appeal period. A 30 percent rating is therefore granted. B. Residuals of Prostate Cancer The veteran's prostate cancer is rated under Diagnostic Code 7528. The initial rating assigned by the RO includes a 100 percent rating prior to February 1, 1998 and a noncompensable rating from that time. Because the maximum rating was assigned prior to February 1, 1998, the Board need not consider that portion of the appeal period; however, the Board will address the propriety of the rating reduction and the propriety of the noncompensable rating assigned from February 1, 1998. See Fenderson v. West, 12 Vet. App. 119, 126-7 (1999). Malignant neoplasms of the genitourinary system warrant a 100 percent rating. 38 C.F.R. § 4.115b, Diagnostic Code 7528 (2002). The adjacent note states: Following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter. If there has been no local recurrence or metastasis, rate on residuals as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 3.105(e) requires that the RO issue a rating proposing the reduction or discontinuance of benefits and, after the veteran had had at least 60 days notice, a final rating action will be taken. The Board finds that the service-connected prostate cancer was last treated in December 1996 and has not returned since that time. It appears that the RO complied with the regulations above and correctly assigned a 100 percent rating for prostate cancer during radiation therapy, which ended in December 1996. The 100 percent rating continued for well over six months, in fact, it was not terminated until February 1, 1998. The rating reduction was based on two VA examinations, which were conducted in March and August 1997. It appears that the RO has fully complied with § 3.105(e). Although the veteran's representative argued in December 1999 that the RO did not comply with 38 C.F.R. § 3.344(a) in reducing the rating for cancer, the Board notes that because the cancer rating had not been in effect for 5 years or more, § 3.344(a) does not apply. See 38 C.F.R. § 3.344(c). The record reflects that all treatment for cancer ended in December 1996 and that there was no recurrence or metastasis of cancer. Therefore, the RO's shift from a rating for cancer to a rating for voiding or renal disabilities, effective from February 1, 1998, was proper. Because service connection has not yet been established for the veteran's end-stage renal disease, it appears that a rating for renal dysfunction is not appropriate. Therefore, the Board will focus on the correct rating to be assigned for other voiding dysfunction or urinary tract infection. Voiding dysfunction is to be rated as urine leakage, frequency, or obstructive voiding. Only the prominent area of dysfunction shall be considered for rating purposes. 38 C.F.R. § 4.115a. For urine leakage or incontinence, a 20 percent evaluation is warranted when there is a need for wearing absorbent materials which must be changed less than 2 times per day. A 40 percent evaluation is warranted when there is a need for wearing absorbent materials that must be changed 2 to 4 times per day. A 60 percent evaluation is appropriate when the use of an appliance is required or when there is a need for wearing absorbent materials which must be changed more than 4 times per day. 38 C.F.R. §§ 4.115a, 4.115b. Comparing the veteran's symptoms to the above rating criteria will be difficult, as the evidence varies widely, due partly to the fact that the veteran was on dialysis prior to May 1999, at which time he received a kidney transplant. An August 1997 VA compensation and pension examiner reported that there was no incontinence. In June 1998, the veteran testified that he had no incontinence but admitted to some urinary leakage. In December 1999, he testified that he had both bowel and bladder incontinence. In March 2000, Dr. Seiler linked urinary incontinence to radiotherapy. A February 2000 treatment report reflects a complaint of urinary incontinence. In May 2000, the veteran reported bowel incontinence. In October 2000, a VA examiner reported bowel and bladder incontinence, although the veteran wore no absorbent material. In February 2002, a VA examiner reported that the veteran did not need a diaper, that there was no stool leakage, and no other incontinence. Because no need for absorbent material has been demonstrated at any time during the appeal period, the Board finds that leakage or incontinence is not the predominant symptom of voiding dysfunction. For urinary frequency, a 40 percent rating may be assigned if the daytime voiding interval is less than an hour, or there is awakening to void at least 5 times per night. A 20 percent rating may be assigned if the daytime voiding interval is between one and two hours, or there is awakening to void 3 to 4 times per night. A 10 percent rating may be assigned if the daytime voiding interval is between 2 and 3 hours or there is awakening to void at least 2 times per night. The veteran's symptoms of urinary frequency will be difficult to assess as the veteran was on dialysis prior to May 1999. During an October 2000 VA examination, the veteran reported urinating every two to three hours and that he arose up to two time per night to urinate. Thus, it appears that the criteria for a 10 percent rating are more nearly approximated, although it must still be determined whether obstructed voiding is the predominant symptom of voiding dysfunction. For obstructed voiding, a 30 percent rating may be assigned if there is urinary retention requiring intermittent or continuous catheterization. A 10 percent rating is warranted for obstructive voiding if there is marked obstructive voiding symptomatology (hesitancy, slow or weak stream, decreased force of stream), with any one of the following: (1) Post void residuals greater than 150 cc; (2) uroflowmetry showing marked diminished peak flow rate (less than 10 cc/sec); (3) recurrent urinary tract infections secondary to obstruction; or, (4) stricture disease requiring periodic dilation every 2 to 3 months. Obstructive symptomatology with or without stricture disease requiring dilation 1 to 2 times per year warrants a noncompensable rating. 38 C.F.R. § 4.115a (2002). The symptoms of the veteran's voiding obstruction are dysuria (painful or difficult urination), peak flow rate of 8 cc/sec and post-void residuals of 100 cc. No urinary catheterization is required. These symptoms more nearly approximate the criteria of a 10 percent rating for obstructed voiding. Judging from the above, it appears that voiding obstruction and urinary frequency are equally predominant symptoms of voiding dysfunction, as each appears to warrant a 10 percent rating; however only one of these is to be considered for rating purposes. The Board will therefore arbitrarily pick voiding obstruction as the predominant symptom of voiding dysfunction. The Board also notes that there is a further restriction in the number of ratings that may be assigned simultaneously for genitourinary dysfunction. According to § 4.115a, diseases of the genitourinary system may result in combinations of renal or voiding dysfunctions and infections and only the predominant area of dysfunction shall be considered for rating purposes. Therefore, having determined that obstructed voiding is the predominant voiding dysfunction, the Board must next determine whether voiding dysfunction predominates over renal dysfunction and urinary tract infection. As noted above, the renal dysfunction in this case, although severe, will not be considered because it is attributed to another, as yet non-service-connected, disability. However, urinary tract infection must be considered. Recurrent symptomatic infection requiring drainage/frequent hospitalization (greater that two time per year), and/or requiring continuous intensive management warrants a 30 percent rating. Long-term drug therapy, 1-2 hospitalizations per year and/or requiring intermittent intensive management warrants a 10 percent rating. 38 C.F.R. § 4.115a (2002). The evidence reflects that urinary tract infections have recurred at various times since February 1, 1998. In February 2000, the veteran was taking Cardura(r) for bladder outlet symptoms. In March 2000, Dr. Seiler mentioned that prostate and urinary tract infections had become difficult to control, such that multiple medications were required. In February 2002, a VA examiner specifically reported that there was no urinary tract infection; however, the examiner then listed current medications, which included antibiotics and other medications. The Board construes this list to be evidence of continuous intensive management. From this evidence, the Board finds that the veteran's urinary tract infections have been manifested by recurring infection requiring continuous intensive management. The Board therefore finds that the criteria for a 30 percent rating for urinary tract infections are more nearly approximated. Recurrent symptomatic urinary tract infection therefore is the predominant area of disability of the genitourinary system. After consideration of all of the evidence of record, including the testimony, the Board finds that the reduction to a noncompensable rating was incorrect. Since February 1, 1998, the evidence favors a 30 percent rating for residuals of prostate cancer based on recurrent symptomatic infection requiring continuous intensive management and the Board so grants a 30 percent rating. C. Extraschedular Consideration 38 C.F.R. § 3.321(b) (2002) provides that where the disability picture is so exceptional or unusual that the normal provisions of the rating schedule would not adequately compensate the veteran for his service-connected disability, an extra-schedular evaluation will be assigned. Where the veteran has alleged or asserted that the schedular rating is inadequate or where the evidence shows exceptional or unusual circumstances, the Board must specifically adjudicate the issue of whether an extraschedular rating is appropriate, and if there is enough such evidence, the Board must direct that the matter be referred to the VA Central Office for consideration. If the matter is not referred, the Board must provide adequate reasons and bases for its decision to not so refer it. Colayong v. West 12 Vet. App. 524, 536 (1999); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In this case, it does not appear that ureteral calculi or residuals of prostate cancer in themselves have caused such difficulties as marked interference with employment or warrant frequent periods of hospitalization or otherwise render impractical the application of the regular schedular standards. In the absence of evidence of such factors, the Board need not remand this matter to the RO for procedural action. See Bagwell v. Brown, 9 Vet. App. 157, 158-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash, 8 Vet. App. at 227. See also VAOPGCPREC. 6-96. ORDER 1. A 30 percent evaluation for ureteral calculi is granted, subject to the laws and regulations concerning the payment of monetary benefits. 2. A 30 percent evaluation for residuals of prostate cancer is granted, subject to the laws and regulations concerning the payment of monetary benefits. ____________________________________________ J. E. Day Veterans Law Judge, 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.