Citation Nr: 1640842	
Decision Date: 10/18/16    Archive Date: 11/08/16

DOCKET NO.  14-28 746	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in San Diego, California


THE ISSUE

Entitlement to service connection for erectile dysfunction (ED), claimed as secondary to medications for post-traumatic stress disorder (PTSD).  


REPRESENTATION

Appellant represented by:	California Department of Veterans Affairs


ATTORNEY FOR THE BOARD

Roya Bahrami, Associate Counsel


INTRODUCTION

The Veteran had active service from May 1968 to May 1970.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California.  It is the only issue ripe for appellate review.  

This appeal is being processed utilizing the paperless, electronic Veterans Benefits Management System and Virtual VA claims processing systems.


FINDINGS OF FACT

Erectile dysfunction was not manifested in service, and the preponderance of the evidence is against a finding that such disability is related to the Veteran's service or was caused or aggravated by his service-connected PTSD or medications taken for it.


CONCLUSION OF LAW

Service connection for erectile dysfunction is not warranted.  38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102 , 3.303, 3.310 (2015).


REASONS AND BASES FOR FINDING AND CONCLUSION

I.  Duties to Notify and Assist

The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014 & Supp. 2015), sets forth VA's duties to notify and assist claimants in substantiating claims for VA benefits.  See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015).

Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim.  38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b).  In order to satisfy its duty to notify the claimant under the VCAA, the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide.  Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002).

For service connection claims, proper notice of what is necessary to substantiate the claim requires that the Veteran be informed of the following five elements:  (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date.  Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006); Quartuccio, 16 Vet. App. at 187. 

The record reflects that the RO provided the Veteran with the requisite notice in May 2012, prior to the initial July 2012 rating decision.  Therefore, the Board finds that VA's duty to notify the Veteran has been satisfied.

Pursuant to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities.  38 U.S.C.A. § 5103A(c)(2).  All records pertaining to the conditions at issue are presumptively relevant.  See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010).  In addition, where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information.  Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)).
Regarding the duty to assist, the Board finds that all relevant facts have been properly developed and that all evidence necessary for equitable resolution of the issues herein decided has been obtained in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c).  The Veteran's service treatment records (STRS) have been associated with the claims file.  All identified and available post-service treatment records have been obtained.  The Veteran was afforded a VA examination in June 2012, as well as an addendum opinion in August 2015.  These reports have been reviewed and found to be collectively adequate to make a determination on the claim.  See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007).

In light of the foregoing, the Board finds that VA's duties to notify and assist have been satisfied and, thus, appellate review may proceed without prejudice to the Veteran.  See Bernard v. Brown, 4 Vet. App. 384, 394 (1993).

II.  Law and Regulations

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service.  38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a).  Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).  

As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service.  Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). 

In addition, secondary service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disease or injury.  38 C.F.R. § 3.310(a).  There must be evidence sufficient to show that a current disability exists and that the current disability was either caused or aggravated by a service-connected disability.  See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).  Additionally, when aggravation of a non-service-connected disability is proximately due to or the result of a service-connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation.  Id.; see also 38 C.F.R. § 3.310(b). 

The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value.  38 U.S.C.A. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a).  In cases where there are conflicting statements or opinions from medical professionals, it is within the Board's province to weigh the probative value of those opinions.  Guerrieri v. Brown, 4 Vet. App. 467 (1993); Harris v. West, 203 F.3d 1347 (Fed. Cir. 2000).  If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue.  38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102.  

III.  Analysis

The Veteran does not claim and the record does not reflect that ED had its clinical onset in service or that it is otherwise related to service.  The Veteran's service treatment records do not reflect complaints or diagnosis of ED in service.  The Veteran does not contend that this disability began in service or that it is related to any injury or event in service.

The Veteran asserts that his ED is secondary to his service-connected PTSD.  The Veteran asserted in his March 2012 claim that it was the medication taken to treat his PTSD that caused his ED and in his substantive appeal, he claimed flashbacks related to PTSD before intercourse, most of the time.

Turning to the medical evidence of record, an April 2004 private treatment record noted a decreased libido, and plan to check testosterone level.  A July 2004 private treatment record indicated that the Veteran reported a diminished frequency in sexual encounters.  He denied difficulty obtaining or maintaining erections most of the time.  Medications included Tylenol, Celebrex, and Celexa.  The examiner assessed situational sexual difficulty, and provided samples of Sildenafil.  A March 2007 private treatment record indicates a diagnosis of ED and a prescription for Viagra.  A June 2010 VA treatment record reflects that the Veteran complained of symptoms of PTSD.  He reported taking Ambien and Oxycodone.  On September 2010 VA PTSD examination, the Veteran reported taking Ambien CR 25 milligrams (mg) at bedtime.  Since February 2011, the Veteran's VA treatment providers had prescribed Sertraline for mood and Temazepam for insomnia.

On June 2012 VA examination, the Veteran reported that he noticed the onset of erectile dysfunction shortly after he got married in 1975.  He began treatment with medication for PTSD in 2010.  His VA treatment records indicate he is treated with Trazadone, gabapentin, temazepam, sertraline, and hydrochlorothiazide.  He was diagnosed with hypertension approximately 2 to 3 years prior.  He began treatment with Viagra in 2012 and stated that he was able to engage in vaginal penetration.  The examiner opined that the Veteran's ED is less likely as not secondary to medications prescribed for PTSD as his ED preceded his treatment with medications.

In May 2013, a letter from a VA physician noted that the Veteran has suffered from chronic PTSD and as a result has a need for treatment with an SSRI antidepressant.  He currently takes sertraline 50 mg nightly in conjunction with Temazepam 45 mg nightly for chronic insomnia.  As a result of his need for sertraline has developed a significant problem with ED.  Therefore it is more likely than not that his PTSD has a secondary complication of ED.

An August 2015 VA opinion notes that the Veteran previously reported the onset of ED in 1975 (40 years ago).  He has numerous risk factors for ED: age (67 years old), general health (treated for hypertension), history of chronic low back pain, and chronic history of alcohol abuse.  During his previous VA examination he indicated that he was taking Zoloft prescribed for PTSD.  However his CPRS chart indicates he had not received a supply of Zoloft from the VA for 8 months prior to that examination and had not seen his psychiatrist for those 8 months, thus calling into question whether he in fact has been taking the medication at all for several months.  Granted, Zoloft is a medication associated with short term problems with erectile difficulty.  However, given the chronicity of his problems with ED, his medical history and the fact that when last prescribed his Zoloft dosage was relatively low, the examiner concluded that the Zoloft therapy (which he is likely not taking) is less likely as not aggravating his ED beyond its natural progression.

Based on the foregoing, the Board finds that service connection for erectile dysfunction is not warranted.

With respect to element (1), current disability, the competent medical evidence of record indicates diagnosis of erectile dysfunction in March 2007.  Accordingly, element (1), current disability, is satisfied.  Element (2) has also been met; the Veteran is service-connected for PTSD.

Turning to element (3), nexus, the competent and probative evidence indicates that the Veteran's erectile dysfunction is not secondary to his service-connected PTSD.

The Board acknowledges the conflicting medical opinion evidence; notably, the negative June 2012 and August 2015 opinions and the positive May 2013 opinion.  Each clinician is competent to evaluate the Veteran's erectile dysfunction and offer opinions in conjunction with the evaluation.  In weighing the probative value of the opinions, the Board finds the June 2012 and August 2015 opinions to be the most probative and persuasive evidence on the issue of a relationship between ED and medications for service-connected PTSD.  Both opinions reflect familiarity with the entire record and are accompanied by rationale.  The August 2015 opinion additionally provided alternate etiologies for the Veteran's ED.  In contrast, the May 2013 opinion does not note review of the Veteran's claims file, nor does it note the Veteran's own report of ED since 1975.  It does not explain the significance of the contradiction between the Veteran's description of his taking Zoloft (sertraline) at the time of examination when the clinical record does not reflect this.  The Board does not find the May 2013 opinion as convincing as the June 2012 and August 2015 opinions.  Consequently, the Board finds that the weight of the medical nexus evidence is against the Veteran's claim for ED as secondary to medication for PTSD.

Lay evidence may be competent on a variety of matters concerning the nature and cause of disability.  Jandreau v. Shinseki, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007).  The general principle that medication may lead to ED is commonly known and, therefore, the Veteran's claim that his ED was caused or aggravated by medication taken for PTSD has some tendency to make a nexus more likely than it would be without such an assertion.  However, once the threshold of competency is met, the Board must consider how much of a tendency a piece of evidence has to support a finding of the fact in contention.  Not all competent evidence is of equal value.  The Board finds the June 2012 and August 2015 VA medical opinions more probative than the Veteran's statements.  The examiners are medical professionals and were able to review the overall record, including the Veteran's history and opinions.  

Finally, while not initially mentioned as a cause of ED, in his substantive appeal, the Veteran claimed that he had flashbacks prior to intercourse mos of the time.  The Veteran did not mention this to the 2012 VA examiner and it was not referenced in the 2013 medical report or elsewhere in the medical evidence.  There is nothing in the clinical record to buttress this claim and it is first mentioned when appealing the denial of his claim that pertinent disability was due to medication taken for PTSD.  Finally, the Veteran does not claim that it prevents an erection; there is no basis to conclude that PTSD itself causes or aggravates ED.  

Ultimately, the Board must conclude that a preponderance of the evidence is against secondary service connection in this case.  As the preponderance of the evidence is against the claim of service connection for erectile dysfunction, the benefit-of-the-doubt doctrine does not apply; the appeal in this matter must be denied.  38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102.


ORDER

Service connection for erectile dysfunction is denied.


____________________________________________
THOMAS J. DANNAHER
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs