Citation Nr: 1216355 Decision Date: 05/07/12 Archive Date: 05/16/12 DOCKET NO. 08-21 744 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUE Entitlement to service connection for a urinary condition, to include incontinence, secondary to medication for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Paul L. Clark, Esq. ATTORNEY FOR THE BOARD L. B. Yantz, Counsel INTRODUCTION The Veteran served on active duty with the United States Army from January 1967 to February 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2007 rating decision by the Seattle, Washington, Regional Office (RO) of the United States Department of Veterans Affairs (VA). In March 2011, the Board denied entitlement to service connection for a urinary condition, to include incontinence, secondary to medication for PTSD. In November 2011, the United States Court of Appeals for Veterans Claims (Court) granted a Joint Motion to remand this claim to the Board. The appeal is REMANDED to the RO. VA will notify the Veteran if further action is required. REMAND The Veteran contends that his urinary condition is related to medication he takes in connection with treatment for his service-connected PTSD. VA treatment records document the following findings. The Veteran first complained of urinary problems on July 19, 2000, and a prostate examination was normal on that occasion. The Veteran began taking Citalopram (also known as Celexa) for his PTSD on July 26, 2000. The Veteran was first noted to have a large prostate in February 2001. In April 2007, the Veteran's VA psychiatrist (Dr. JSS) noted his review of a clinical database and his discussion with a pharmacist, and then stated: "There is a potential for anticholinergic effect which could be exacerbating this [urinary] problem. This is potential with all SSRI's and Citalopram is probably less in this regard. This note documents that there is potential for exacerbation by Citalopram. I have advised patient that he does have benign prostatic hypertrophy (BPH) and should discuss this with primary care provider or urology for proper evaluation and treatment." At a March 2008 QTC examination, the Veteran reported urinary dysfunction for 12 years, and related it to when he started taking Citalopram 12 years earlier. He complained of increased frequency, urgency, and hesitancy with urination. The examiner diagnosed urinary dysfunction associated with medication. He noted that the subjective factors were complaints of urinary problems since on Citalopram, and that the objective factors were the Veteran's and his wife's statements, which were consistent with urinary dysfunction with medication. In June 2008, an independent medical opinion was rendered by a VA physician (Dr. JT). The physician opined that the Veteran's urinary symptoms were secondary to his BPH and less likely related to Citalopram. He reviewed the side effect profile for Citalopram and noted that "at best the reaction in 0.1 to 1 percent of the population includes urination disorder or retention associated with urinary frequency." He reviewed the VA treatment records and noted "convincing evidence of BPH on several documentations." The physician noted that while there was "no specific reference made objectively" as to whether the Veteran had evidence of urinary incontinence, the Veteran "certainly had evidence of increased urinary frequency and urgency, which most likely are related to BPH." The medical opinions of record are inadequate. Dr. JSS's April 2007 opinion is speculative in nature. The March 2008 VA examiner's opinion does not take into account that the Veteran first complained of urinary problems one week before he started taking Citalopram in July 2000. Dr. JT's June 2008 independent medical opinion does not take into account that the Veteran first complained of urinary problems when his prostate was assessed as normal in July 2000, and was not diagnosed with a large prostate until February 2001. The Veteran is to be scheduled for a VA genitourinary examination to obtain an opinion regarding the relationship between any current urinary condition and the medication that he takes for his service-connected PTSD. Accordingly, the case is REMANDED for the following: 1. Schedule the Veteran for a VA genitourinary examination. The claims folder must be reviewed in conjunction with the examination. The examiner is to opine as to whether it is at least as likely as not (a 50 percent or greater probability) that any current urinary condition is caused or aggravated by the medication that the Veteran takes for his service-connected PTSD, taking into account the chronology of the Veteran's medical history. A complete rationale for all opinions expressed must be provided. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 2. Review the claims file to ensure that the foregoing development is completed, and arrange for any additional development indicated. Then readjudicate the claim on appeal. If the benefit sought remains denied, issue an appropriate supplemental statement of the case and provide the Veteran and his representative the requisite period of time to respond. The case should then be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). _________________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2011).