Citation Nr: 1221293 Decision Date: 06/19/12 Archive Date: 06/29/12 DOCKET NO. 09-03 950 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for erectile dysfunction, to include as secondary to the service connected disabilities of type-II diabetes mellitus and posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: David L. Huffman, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The Veteran had active duty service from May 1965 to May 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran's notice of disagreement was received in May 2008. A statement of the case was issued in December 2008, and a substantive appeal was received in January 2009. The Veteran appeared at an April 2012 hearing before the Board at the RO. A transcript is of record. The appeal is REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the appellant if further action is required. REMAND During the course of this appeal, the Veteran's contentions have evolved from originally featuring an assertion that his erectile dysfunction (ED) was caused or aggravated by his diabetes mellitus disease pathology, to now more recently clarifying that he believes his ED may be caused or aggravated by side-effects of medications taken to treat multiple service-connected disabilities including PTSD. The Veteran underwent a VA examination in April 2008, and the report from that examination addresses, in pertinent part, only the question of whether the Veteran's ED is "secondary" to his type-II diabetes mellitus. The April 2008 VA examination report concludes that "his testosterone level was 206 which is below normal. His erectile dysfunction is therefore less likely than not secondary to his type 2 diabetes mellitus but is more likely from hypogonadism." The April 2008 VA examination report does not address the Veteran's more recently clarified and broadened contentions such as those concerning side-effects from medications used to treat service-connected PTSD. The April 2008 VA examination report also does not address with adequate clarity whether the diabetes pathology may have caused or aggravated the Veteran's ED; the opinion does not make it clear that both causation and aggravation were considered in the medical analysis. The Veteran has presented competent testimony indicating that he experiences symptoms of ED (some medical evidence also appears to support this testimony), and the Veteran has identified plausible theories regarding the possibility of a link between the ED symptoms and treatment for service-connected disabilities. The Veteran and his attorney have submitted publicly available medical literature together with argument suggesting that the VA examiner's diagnosis of hypogonadism did not adequately establish a sufficiently considered basis for that diagnosis consistent with medical principles, and suggesting that the VA examiner's findings are not adequate to medically exclude the Veteran's contended etiologies. The Veteran and his attorney have submitted laboratory results, including testosterone levels, from an earlier date together with argument that those earlier results were normal and that these contradict or cast doubt upon the VA examiner's diagnosis. The Veteran's attorney has also argued that the Veteran's success in fathering children contradicts or casts doubt upon the VA examiner's diagnosis. Significantly, the Veteran and his attorney have also submitted publicly available medical warning information concerning the recognized risk of erectile dysfunction from the use of anti-depressant medications, including specifically Prozac; the Veteran is shown to have been prescribed Prozac for psychiatric treatment during a portion of the period pertinent to this appeal. The Board observes that similar warning information is available concerning erectile dysfunction side-effects associated with several other medications that the Veteran's VA treatment records show to have been used in his psychiatric treatment during various significant periods of time. Specifically, the Board notes that in addition to Prozac, the Veteran has apparently been prescribed medications including Zoloft, Paxil, and Fluoxetene; the Board observes that each of these is associated with some notable risk of possible erectile dysfunction in publicly available medical literature, drug profiles and warning labels. However, the Board notes that there is currently no affirmative medical evidence finding actual causation or aggravation of the Veteran's ED from service-connected disease (including treatment thereof). The Veteran's VA treatment records show that the Veteran has reported the ED complaints during medication reviews, but these reports contain no clear medical opinion squarely addressing the matter of controversy in this case. The only medical opinion of record attempting to address part of the set of etiological questions in this case, the April 2008 VA examination report, appears to be inadequate for appellate review but also does not offer any suggestive support of the claim. An adequate VA examination with medical opinion is essential in this case, as the Veteran's service-connected pathologies and treatment may present notable risk factors for causation or aggravation of ED. The Veteran also has pathologies and medications which are not service connected which also may be potentially significant to the medical analysis of his ED etiology (such as, for instance, the Veteran's non-service-connected hypertension and the hydrochlorothiazide prescribed for treatment). The Board finds that a new VA examination report is warranted to fully and adequately address the medical questions raised by the Veteran's contentions in this case. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be scheduled for an appropriate VA examination by a medical doctor to ascertain the etiological relationship between the Veteran's erectile dysfunction and his service-connected PTSD and service-connected type-II diabetes mellitus (to include necessary medical treatment for those disabilities). It is imperative that the claims file be made available to the examiner for review in connection with the examination. After reviewing the claims file and examining the Veteran, the examiner should respond to the following: a) Is it at least as likely as not (a 50% or higher degree of probability) that the Veteran's erectile dysfunction is proximately due to or caused by his PTSD (or any medication prescribed in the treatment thereof)? In answering this question, please specifically discuss the particular psychiatric medications prescribed to treat the Veteran's PTSD both currently and in the past. b) Is it at least as likely as not (a 50% or higher degree of probability) that the Veteran's erectile dysfunction has been aggravated in severity by his PTSD (or any medication prescribed in the treatment thereof)? In answering this question, please specifically discuss the particular psychiatric medications prescribed to treat the Veteran's PTSD both currently and in the past. c) Is it at least as likely as not (a 50% or higher degree of probability) that the Veteran's erectile dysfunction is proximately due to or caused by his diabetes mellitus (or any medication prescribed in the treatment thereof)? d) Is it at least as likely as not (a 50% or higher degree of probability) that the Veteran's erectile dysfunction has been aggravated in severity by his diabetes mellitus (or any medication prescribed in the treatment thereof)? e) Is it at least as likely as not (a 50% or higher degree of probability) that the Veteran's erectile dysfunction has been caused or aggravated in severity by any single or combination of his service-connected disabilities or medications prescribed to treat service-connected disabilities? In answering this question, please specifically discuss the April 2008 VA examination report's findings concerning hypogonadism and a low testosterone count, and please address the recently submitted medical evidence including laboratory results showing the Veteran's testosterone level in 1985. Detailed reasons should be furnished for all opinions. 2. After completion of the above, the RO should review the expanded record and determine if the benefit sought can be granted. If the claim remains denied, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters 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). _________________________________________________ ALAN S. PEEVY 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).