Citation Nr: 1633720 Decision Date: 08/25/16 Archive Date: 08/31/16 DOCKET NO. 12-30 826A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Matthew Miller, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from May 1969 to March 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office in Waco, Texas. In a September 2014 decision, the Board denied the claim for service connection for ED to include as secondary to service-connected PTSD. The Veteran appealed the Board's September 2014 decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2015 Order, the Court granted a Joint Motion of the parties to vacate the Board's decision and remanded the case to the Board for action consistent with the terms of the Joint Motion. In September 2015, the Board remanded the claim for additional development. The claim has since returned to the Board for further consideration. This appeal was processed using the Virtual VA and Veterans Benefits Management System paperless claims processing systems. Any future consideration of this appellant's case should take into account the existence of these records. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Review of the record reveals that a remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claim. Specifically, remand is required to receive an addendum opinion and/or a new examination The Veteran is seeking service connection for erectile dysfunction that he contends is secondary to his service-connected PTSD. As indicated above, the Court granted the parties' Joint Motion for Remand, in which the parties agreed that the Board's September 2014 decision failed to address whether the Veteran's service-connected PTSD, as opposed to any medications prescribed for it, caused or aggravated his ED. In this regard, a December 2010 treatment record noted that the Veteran indicated that his ED coincided with the onset of his PTSD symptoms. In the same note, the Veteran also indicated that he had experienced ED symptoms since leaving Vietnam. In addition, the parties noted that an August 2011 VA examination was deficient because the examiner did not evaluate all of the Veteran's PTSD medications to determine whether those medications were the potential cause or aggravator of his ED. In the August 2011 VA examination report, the examiner opined that two of the Veteran's PTSD medications, Elavil (Amitriptyline) and Aprazolam (Xanax), were likely not the cause of his ED. Instead, the examiner opined that the Veteran's other health issues, such as hypertension, nephrotic syndrome, history of respiratory and renal failure, and pericardial effusion were likely the cause of his ED. In support of this opinion, the examiner noted that both Harrison's Principle of Medicine and the Physician's Desk Reference did not contribute ED to either Elavil or Alprazolam. However, as noted by the parties to the Joint Motion, the August 2011 VA examiner failed to consider all medications, not just Elavil and Aprazolam, that the Veteran has been prescribed to treat his service-connected PTSD. In particular, the Board notes that VA medical records indicate that the Veteran has also been prescribed Prozac (Fluoxetine), Zoloft (Sertraline), Paxil (Paroxetine), Celexa (Citalopram), Neurontin (Gabapentin), Effexor (Venlafaxine HCL), Wellbutrin (Bupropion), Trazodone, Cymbalta (Duloxetine HCL), Seroquel (Quetiapine Fumarate), Lamictal (Lamotrigine), Paxil (Paroxetine), Klonopin (Clonazepam), Serzone (Nefazodone), Tofranil (Imipramine), Lithium, Depakote, Ativan (Lorazepam) for the treatment of his PTSD. In September 2015, the Board remanded the Veteran's claim for an additional medical opinion to addresses whether the Veteran's ED is related to service or is caused or aggravated by the Veteran's service-connected PTSD, to include any medication that has been prescribed to treat his service-connected PTSD. Pursuant to the Board's September 2015 remand, the Veteran was afforded another VA examination in November 2015. The examiner noted that the Veteran reported that his erection problems began around 2002 and that they had worsened over time. The examiner also noted that the Veteran has declined prescription medication for his ED. The examiner reported that the Veteran's ED was initially diagnosed in 2010. The examiner remarked that the etiology of the Veteran's ED was "age, hypertension and associated medication treatment, [and] low testosterone." The examiner then determined that the Veteran's ED "is not at least as likely as not (less than 50 percent) related to service because the Veteran first complained of ED in 2002, nearly 31 years after discharge. The examiner also found that the Veteran's claimed ED condition "is not at least as likely as not (less than 50 percent) caused by his service-connected PTSD, to include any medications prescribed to treat his PTSD." The examiner reasoned that in addition to age, the best predictors of ED are diabetes mellitus, hypertension, obesity, dyslipidemia, cardiovascular disease, smoking, and medication use. The Veteran's multiple medical conditions of hypertension and associated medications, low testosterone level and hyperlipidemia collectively outweigh the single condition of PTSD and associated medication treatment of amitriptyline. Based on Micromedex, erectile dysfunction is not listed as a side effect of alprazolam and mirtazapine. Furthermore, the Veteran's ED symptoms first present itself at age 53 in 2002, over 10 years after initiation of amitriptyline for chronic leg pain treatment. The examiner then determined that the Veteran's claimed ED condition "is not at least as likely as not (less than 50 percent) aggravated (permanently worsened beyond the natural progress of the disorder) by his service-connected PTSD, to include any medications prescribed to treat his PTSD. The examiner explained that the "Veteran reports intermittent difficulty with erection initially noted about 2002 when he was 53 years old and worsened over time due to age progression, additional antihypertensive medications, development of hyperlipidemia and low testosterone levels. In general, side effects of a medication are temporary and resolve with withdrawal of medication." That Board observes that the Veteran's representative submitted a request for a new examination in July 2016. Essentially, the representative suggests that the November 2015 examination was inadequate because it did not address the PTSD symptoms experienced by the Veteran and discuss whether his PTSD symptoms had an effect on his ED. The Board notes that there are medical records which appear to document that the Veteran's onset of ED began earlier than the 2002 date that the examiner reported. Specifically, a February 1999 VA examination indicated that the Veteran was not sexually active. Moreover, at the Veteran's October 1998 RO hearing, he claimed that his marriage was suffering because he could not maintain an erection and associated his ED with his PTSD symptoms and medications. Additionally, in an April 1998 report, the Veteran stated that he was hesitant to engage in sexual relations with his wife and attributed this with the escalation of his PTSD symptomatology that began around 1991. Finally, a December 1992 VA PTSD examination noted that the Veteran does not have much of a sexual appetite. Thus, the Board finds the November 2015 VA examination to be inadequate for rating purposes. When the VA "undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, [it] must provide an adequate one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion will be considered adequate when it is based upon consideration of the Veteran's prior medical history and examinations and provides a sufficiently detailed description of the disability so that the Board's "evaluation of the claimed disability will be a fully informed one." Id. (internal quotation marks omitted); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). It is "essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history." 38 C.F.R. § 4.1 (2015). If a diagnosis is not supported by the findings on the examination report or if the report does not contain sufficient detail, it is incumbent upon the Board to return the report as inadequate for rating purposes. 38 C.F.R. § 4.2 (2015). Here, the November 2015 examiner did not address whether the Veteran's PTSD symptoms caused or aggravated his ED. The Court has also held that an adequate examination requires that the examiner providing the report or opinion be fully cognizant of the claimant's past medical history. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (Vet. App. 2008). Here, the examiner's rationale was erroneously based on reports that the Veteran's ED problems began in 2002. However, review of the Veteran's claims file reveals that he first reported a low sex drive and problems with ED around 1991, which he associated with an increase in his PTSD symptoms. Accordingly, the case is REMANDED for the following action: 1. Forward the entire claims file, to include the VBMS and Virtual VA file, to an appropriate examiner, one who has not previously examined the Veteran, for an etiology and aggravation opinion. The file must be reviewed and such review must be documented in the report. The report should include discussion of the Veteran's documented medical history and assertions. All indicated tests should be accomplished and all clinical findings should be reported in detail. The examiner should reconcile the November 2015 examiner's opinion. (a) The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's ED is related to service. In rendering this opinion, the examiner must consider the Veteran's statements regarding the onset and statements regarding the continuity of symptomatology; (b) The examiner should offer an opinion as to whether it is at least as likely as not (50 percent or greater probability), that the Veteran's ED is caused by his service-connected PTSD, to include any medications prescribed to treat his PTSD (to include, but not limited to: Prozac (Fluoxetine), Zoloft (Sertraline), Paxil (Paroxetine), Celexa (Citalopram), Neurontin (Gabapentin), Effexor (Venlafaxine HCL), Wellbutrin (Bupropion), Trazodone, Cymbalta (Duloxetine HCL), Seroquel (Quetiapine Fumarate), Lamictal (Lamotrigine), Paxil (Paroxetine), Klonopin (Clonazepam), Serzone (Nefazodone), Tofranil (Imipramine), Lithium, Depakote, Ativan (Lorazepam)); (c) The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's ED is aggravated (permanently worsened beyond the natural progress of the disorder) by his service-connected PTSD symptoms, to include any medications prescribed to treat his PTSD. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements of continuity of symptoms since service, and may not disregard those statements merely because there was no treatment. The examiner is also advised that the Veteran's claimed ED and associated sexual problems were first documented around 1991, which he attributed to the escalation of his PTSD symptomatology. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a conclusion as it is to find against it. The rationale for all opinions expressed must be provided and the examiner must clearly articulate the reasons for his or her conclusions. If an opinion cannot be provided without resort to speculation, it must be noted in the opinion report, and a rationale should be provided for that conclusion. A new examination may be conducted if needed. 2. Thereafter, readjudicate the issues on appeal. If the benefits sought are not granted, issue a supplemental statement of the case and afford the Veteran and his representative the appropriate opportunity to respond before returning the file to the Board for further appellate consideration, if warranted. 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 2014). _________________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2015).