Citation Nr: 1032003 Decision Date: 08/25/10 Archive Date: 09/01/10 DOCKET NO. 05-06 940 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a bilateral hearing loss. 2. Entitlement to an evaluation in excess of 20 percent for service-connected Reiter's syndrome with degenerative disc disease of the lumbar spine (low back disability). 3. Entitlement to a compensable evaluation for hypertension from April 30, 2003 to March 7, 2007 and to an evaluation in excess of 10 percent beginning March 8, 2007. 4. Entitlement to a compensable evaluation for Reiter's syndrome with urethritis (urethritis) from April 30, 2003 to March 8, 2010. 5. Entitlement to a compensable evaluation for urethritis beginning March 8, 2010. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. W. Loeb INTRODUCTION The Veteran served on active military duty from June 1965 to November 1985; his military occupational specialty (MOS) was Missile Systems Technician. In April 2008, the Board of Veterans' Appeals (Board) reopened a claim for service connection for a bilateral hearing loss and remanded the reopened claim and the increased rating issues on appeal to the Department of Veterans Affairs (VA) Regional Office in Waco, Texas (RO) for additional development. VA examinations were conducted in March 2010, and there has been substantial compliance with the April 2008 remand. The Veteran testified at a personal hearing before the undersigned Veterans Law Judge sitting at the RO in February 2008. A transcript of the hearing is on file. FINDINGS OF FACT 1. All known and available service medical records have been obtained; the Veteran has been advised under the facts and circumstances of this case as to the evidence which would substantiate his claim for service connection for a hearing loss and for increased ratings for low back disability, hypertension, and urethritis; and he has otherwise been assisted in the development of his claims. 2. The Veteran's statements that he has experienced hearing loss due to service are competent, non-credible, non-probative evidence. 3. The Veteran does not have a bilateral hearing loss that is causally related to service. 4. The evidence does not show flexion of the lumbar spine to 30 degrees or less, favorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes due to the service-connected low back disability. 5. The Veteran had diastolic blood pressure readings of 100 millimeters (mm.) or more while taking medication for control of hypertension beginning March 8, 2007. The evidence does not show diastolic readings predominantly 100 or more or systolic readings predominantly 160 or more from April 30, 2003 to March 8, 2007 and does not show diastolic reading predominantly 110 or more or diastolic readings of 200 or more during the appeal period. 6. There were no significant signs or symptoms of urethritis prior to VA examination on March 8, 2010. 7. The Veteran complained of a daytime voiding interval between one and two hours on VA examination on March 8, 2010. CONCLUSIONS OF LAW 1. Hearing loss was not incurred in or aggravated by active duty; nor may sensorineural hearing loss be presumed to have been incurred therein. 38 U.S.C.A. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.1, 3.102, 3.303, 3.307, 3.309 (2009). 2. The criteria for the assignment of an evaluation in excess of 20 percent for the service-connected low back disability have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a including Diagnostic Code 5243 (2009). 3. The criteria for the assignment of a compensable evaluation from April 30, 2003 to March 7, 2007 and to an evaluation in excess of 10 percent beginning March 8, 2007 for the service- connected hypertension have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a including Diagnostic Code 7101 (2009). 4. The criteria for the assignment of a compensable evaluation for the service-connected urethritis from April 30, 2003 to March 7, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a including Diagnostic Codes 7599-7512 (2009). 5. By extending the benefit of the doubt to the Veteran, the criteria for the assignment of a 20 percent evaluation for the service-connected urethritis beginning March 8, 2010 have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.71a including Diagnostic Codes 7599-7512 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Assist and Notify The Board has considered the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 and Supp. 2007). The regulations implementing VCAA have been enacted. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2009). VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. See also Quartuccio v. Principi, 16 Vet. App. 183 (2002). After having carefully reviewed the record on appeal, the Board has concluded that the notice requirements of VCAA have been satisfied with respect to the issues decided herein. The notice and assistance provisions of VCAA should be provided to a claimant prior to any adjudication of the claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO sent the Veteran a letter in May 2004, prior to adjudication, that informed him of the requirements needed to establish entitlement to service connection and entitlement to an increased evaluation. Another letter was sent in April 2008. In accordance with the requirements of VCAA, the letters informed the Veteran what evidence and information he was responsible for obtaining and the evidence that was considered VA's responsibility to obtain. Additional private evidence was subsequently added to the claims files after the May 2004 letter. In compliance with the duty to notify the Veteran of what information would substantiate his claim, the Veteran was informed in the April 2008 letter on disability ratings and effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA has a duty to assist the claimant in obtaining evidence necessary to substantiate a claim. VCAA also requires VA to provide a medical examination when such an examination is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159. Relevant VA examinations were conducted in March 2010. The Board concludes that all available evidence has been obtained and that there is sufficient medical evidence on file on which to make a decision on the issues decided on appeal. The Veteran has been given ample opportunity to present evidence and argument in support of his claims, including at his February 2008 personal hearing. All general due process considerations have been complied with by VA, and the Veteran has had a meaningful opportunity to participate in the development of the claim. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); 38 C.F.R. § 3.103 (2007). Analyses of the Claims In its decisions, the Board is required to apply case law issued by the Courts, statutes enacted by Congress, regulations issued by VA, and precedential opinions issued by VA's Office of General Counsel. Service Connection Claim The Veteran seeks service connection for a bilateral hearing loss. Having carefully considered the claim in light of the record and the applicable law, the Board is of the opinion that the preponderance of the evidence is against the claim and that the appeal will be denied. Service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 303, 305 (1992). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 hertz, in ISO units, is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2009). The Veteran has contended, including at his February 2008 hearing, that he has a hearing disorder that began in service. During a September 1984 service department physical examination, the Veteran was assigned a "PULHES" designation of hearing capability of 2, indicating that the Veteran possessed some medical condition or physical defect that might impose some limitations on classification and assignments. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992); (Observing that the "PULHES" profile reflects the overall physical and psychiatric condition of the veteran on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service. A June1985 audiological report shows pure tone thresholds from 500 to 4000 hertz in both ears that were 25 decibels or lower, except for a threshold of 35 decibels at 500 and 2000 hertz and of 30 decibels at 1000 hertz in the right ear. It was noted on VA compensation and pension evaluation in February 1986 that the Veteran had a past history of hearing loss. A March 1986 hearing examination by a VA audiologist showed results within the VA definition of normal, with bilateral pure tone thresholds of 25 decibels or fewer from 500 to 4000 hertz. The audiologist noted that the Veteran's bilateral hearing was normal by VA definition. VA outpatient records for April 2005 reveal that the Veteran was seen by VA Audiology. Although the report does not contain the actual record of audiometric testing, the Veteran was evaluated for a hearing aid due to complained of sensorineural hearing loss. The Veteran testified at his personal hearing in February 2008 that he has hearing loss due to exposure to acoustic trauma in service. The Veteran noted on VA audiological evaluation in March 2010 that he had exposure to acoustic trauma both in service and after discharge. Audiological testing showed bilateral sensorineural hearing loss. After review of the claims files and examination of the Veteran, the examiner concluded that hearing loss was less likely as not due to service because the June 1985 service department hearing test showed normal hearing in the left ear and a mild low frequency hearing loss in the right ear. The examiner noted that these findings were inconsistent with hearing loss caused by noise exposure. The examiner also noted that a VA audiological evaluation in March "1988" showed normal hearing in both ears, which he interpreted as indicating that the Veteran's current hearing loss developed after the post-service examination. The Board notes that although the examiner mistakenly perceived the date of the initial post-service VA examination as 1988, rather than 1986, this error would not affect the conclusion of the opinion that the Veteran's current chronic hearing loss began after discharge. This initial evidence of a chronic hearing loss under VA criteria is not until April 2005, which is many years after service discharge. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). Because there is no evidence of a chronic hearing loss at service discharge, no evidence of continuity of symptomatology for a number of years after service discharge, and because the only nexus opinion on file is against the claim for service connection for a bilateral hearing loss, service connection for a bilateral hearing loss is not warranted. The Board has considered the Veteran's hearing testimony and the written statements on file in support of his service connection claim. To the extent that he has alleged that he has had a hearing disorder since service, the Board finds that while the Veteran is competent to make this contention, the contention is not credible, as the objective evidence of record does not substantiate his allegation, and he is not competent to diagnose his own hearing loss within the meaning of VA regulation. The absence of a hearing disability on VA examination in March 1986 or evidence of a hearing loss for many years after service, as well as the March 2010 nexus opinion, contradict his assertion. Finally, in reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the service connected claim denied above, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Claims Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Schedule). 38 C.F.R. Part 4 (2009). The percentage ratings contained in the Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2009). Separate diagnostic codes identify the various disabilities. In considering the severity of a disability it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2009). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Nevertheless, 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. See Francisco v. Brown, 7 Vet. App. 55 (1994). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2009). Low Back The Veteran was originally granted service connection for a low back disability by rating decision in April 1986 and assigned a 20 percent rating under Diagnostic Codes 5299-5002, effective November 30, 1985. A claim for an increased rating was received by VA in April 2004. An increase was denied by rating decision in October 2004 under Diagnostic Code 5243, and the Veteran timely appealed. A July 2005 rating decision granted a temporary total disability rating for the Veteran's low back disability from January 10, 2005 to April 30, 2005. The Veteran has contended, including at his February 2008 hearing, that he warrants a higher evaluation because he cannot bend his low back, as there is fusion of L4-L5. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements and 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. DeLuca v. Brown, 8 Vet. App. 202 (1995). Arthritis due to trauma, which is established by x-ray findings, is to be rated as degenerative arthritis, which is rated under Diagnostic Code 5003. Diagnostic Code 5003 states that degenerative arthritis will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, x-ray evidence of involvement of 2 or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations warrants a 20 percent evaluation. X-ray evidence of involvement of 2 or more major joints or 2 or more minor joints warrants a 10 percent evaluation. See 38 C.F.R. § 4,71a, Diagnostic Codes 5003, 5010 (2009). A 50 percent evaluation is assigned for disability of the thoracolumbar spine when there is unfavorable ankylosis of the entire thoracolumbar spine. A 40 percent rating is assigned when forward flexion of the thoracolumbar spine is 30 degrees or less or when there is favorable ankylosis of the entire thoracolumbar spine. A 20 percent evaluation is assigned when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees, or with muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 10 percent evaluation is assigned when forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees, or the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees, or with muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Diagnostic Codes 5242 (2009). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 45 degrees, bilateral rotation is 0 to 30 degrees, and lateral flexion to either side is 0 to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5237, Note (2) (2009); see also 38 C.F.R. § 4.71a, Plate V (2009). The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. at Note (2) (2009). Each range of motion measurement is rounded to the nearest five degrees. Id. at Note (4) (2009). The normal combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5237, Note (2) (2009). The notes to the revised rating formula for diseases and injuries to the spine state that any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be rated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Note (1) (2009). Intervertebral disc syndrome (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table) (2009). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that a 10 percent rating is awarded for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is awarded for disability with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is assigned for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months. A maximum 60 percent rating is warranted when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. Note 1 provides that for the purposes of evaluations under Diagnostic Code 5293, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. "Chronic orthopedic and neurological manifestations" means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. 38 C.F.R. § 4.71a (2009). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. See Butts v. Brown, 5 Vet. App. 532 (1993). Private treatment records for February 2004 reveal diagnoses of symptomatic spondylolisthesis of L4-L5, mechanical back pain, and bilateral leg pain. When examined by VA in October 2004, the complained of low back pain, weakness, stiffness, fatigability, and lack of endurance. Range of motion of the thoracolumbar spine included flexion from 0 to 90 degrees; the Veteran complained of low back pain from flexion of 90 degrees recovering to the baseline position. Extension was painless from 0 to 30 degrees, although the Veteran complained of pain recovering to the baseline position. Both lateral bending and rotation were from 0 to 30 degrees bilaterally with no pain. There was additional limitation and functional impairment mostly due to pain during flare-up and on daily routine activity with strenuous movement. The diagnoses were chronic low back pain; degenerative disc disease L4-L5 with bilateral lower extremity sensory radiculopathy; and history of spondylolisthesis L4-L5, grade I. Private treatment records from October 2004 to April 2005 reveal that the Veteran underwent L5-S1 transforaminal lumbar interbody fusion with pedicle instrumentation, with rapid recovery. On VA spinal evaluation in October 2005, which included review of the claims file, range of motion included flexion from 0 to 90 degrees, with pain from 15 to 90 degrees; extension from 0 to 25 degrees, with pain beginning at 18 degrees; lateral flexion from 0 to 25 degrees on the right and 0 to 14 degrees on the left; and bilateral rotation from 0 to 30 degrees. The Veteran was able to complete 10/10 forward flexions but had limitations due to pain, weakness, and fatigue. The diagnosis was Reiter's syndrome with degenerative disc disease of the lumbar spine, status post surgery. According to private treatment records dated in April 2008, the Veteran did not have any joint pain with motion. April 2008 x- rays revealed that the Veteran had mild degenerative changes of L5-S1. Recurrent back pain was noted in August 2009. The impressions on an April 2009 MRI from Austin Radiological Association are postoperative changes at L5-S1 which appeared satisfactory, and congenital and degenerative factors resulting in moderate central stenosis at L3-L4 and L4-L5, worse since the prior study. Private treatment records dated from April to August 2009 reveal limited range of motion of the sacroiliac joint but full motion of the thoracic spine. The Veteran received lumbar injections in May, June, and July. According to a June 2009 medical report from M. S. Mason, D.C., the Veteran had been treated since February 2009, and had shown continued improvement but still experienced some pain (3/10) with lumbar extension; muscle spasms were also reported. When examined by VA in March 2010, which included review of the claims files, range of motion of the low back included 0 to 80 degrees of flexion, 0 to 20 degrees of extension, lateral bending from 0 to 15 degrees on the right and from 0 to 20 degrees on the left, and rotation from 0 to 10 degrees on the right and from 0 to 15 degrees on the left. There were no incapacitating episodes, no objective evidence of pain on motion, and no additional loss on repetitive motion. The diagnoses were degenerative disc disease of the thoracolumbar spine, previous fusion at L5-S1, disc disease more significant in the thoracic area, and small osteophytes throughout the lumbar and thoracic spine. The medical evidence noted above does not show active flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Flexion of the low back was to 90 degrees on evaluation in October 2004, with limitation on prolonged activity or repetitive movement. Although the Veteran complained of pain beginning at 15 degrees on flexion of the thoracolumbar spine in October 2005, he was able to flex to 90 degrees at that time and could flex to 80 degrees without pain when examined in March 2010. Additionally, there is no medical evidence of intervertebral disc syndrome with resulting incapacitating episodes confirmed by a physician that would warrant evaluation under the criteria for rating intervertebral disc syndrome based on incapacitating episodes. Consequently, a rating in excess of 20 percent for the lumbosacral spine is not warranted during the appeal period at issue under the current rating criteria for the spine. See Francisco, supra. The Veteran is currently receiving compensable evaluations for sciatica of each lower extremity. See 38 C.F.R. § 4.71a, Diagnostic Code 5243 Note (1) (2009). An increased evaluation can also be assigned for low back disability involving loss of motion when there is additional functional impairment. As flexion of the thoracolumbar spine has always been greater than 60 degrees. The functional impairment reported on VA evaluation in October 2004 has been taken into consideration in assigning the Veteran a 20 percent rating for his low back disorder. Moreover, the recent examination results in March 2010 do not show any additional impairment on repetitive motion. Hypertension An April 1986 rating decision granted service connection for hypertension and assigned a noncompensable evaluation effective November 30, 1985 under Diagnostic Code 7101. A claim for increase for hypertension was received by VA in April 2004. An April 2010 rating decision granted a 10 percent evaluation for hypertension effective March 8, 2007. The Veteran continued his appeal. A 10 percent evaluation is warranted for hypertensive vascular disease (essential arterial hypertension) where the diastolic pressure, the lower number in a blood pressure reading, is predominantly 100 or more or when systolic pressure, the higher number, is predominantly 160 or more; a minimum 10 percent evaluation is also assigned when continuous medication is shown necessary for the control of hypertension and there is a history of diastolic blood pressure of predominantly 100 or more. A 20 percent evaluation requires diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more. A 40 percent evaluation requires diastolic pressure predominantly 120 or more, and a 60 percent evaluation requires diastolic pressure predominantly 130 or more. Hypertension or isolated systolic hypertension must be confirmed by readings taken 2 or more times on at least 3 different days. 38 C.F.R. § 4.104, Code 7101. The term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. Id. at Note (1). A review of the medical evidence reveals multiple blood pressure readings between April 2003, which is one year prior to the claim for increase, and March 8, 2007, the effective date of a 10 percent grant. Those blood pressure readings are predominantly under 160 mm systolic and under 100 mm diastolic. In fact, there are virtually no blood pressure readings of at least 160 systolic or 100 diastolic prior to February 2006. Of the seven blood pressure readings provided by M. Garcia, M.D., between February 2006 and March 2007, only two are 100 or more diastolic and only one is 160 or more systolic. Consequently, a compensable rating prior to March 8, 2007 is not warranted. A rating is excess of 10 percent is not warranted for hypertension after March 8, 2007 because there are no systolic blood pressure readings of at least 200 mm or diastolic reading of 110 mm or more. Blood pressure readings on VA evaluation in March 2010 were 130/72, 120/76, and 132/70. The Board would also note that the Veteran testified at his February 2008 personal hearing that his hypertension is well controlled on Benicar. Urethritis An April 1986 rating decision granted service connection for urethritis and assigned a noncompensable evaluation effective November 30, 1985 under Diagnostic Code 7599-7512. A claim for increase for urethritis was received by VA in April 2004, which was denied by rating decision in October 2004. The Veteran timely appealed. A designation of a diagnostic code that ends in "99" reflects that the disability is a condition not specifically listed in the Rating Schedule, and hyphenation with another diagnostic code indicates that the disability has been rated as analogous to the second code listed. See 38 C.F.R. §§ 4.20, 4.27 (2009). The Veteran's urinary disorder is rated as analogous to Diagnostic Code 7512, for chronic cystitis, including interstitial and all etiologies, infectious and non-infectious. The regulation directs that disabilities rated under this code should be rated as voiding dysfunctions. Voiding dysfunctions are to be rated as urine leakage, urinary frequency, or obstructed voiding. Evaluation under urine leakage involves ratings ranging from 20 to 60 percent and contemplates continual urine leakage, post- surgical urinary diversion, urinary incontinence, or stress incontinence. When these factors require the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day, a 60 percent evaluation is warranted. When there is leakage requiring the wearing of absorbent materials which must be changed two to four times per day, a 40 percent disability rating is warranted. A 20 percent rating contemplates leakage requiring the wearing of absorbent materials which must be changed less than two times per day. 38 C.F.R. § 4.115a. Urinary frequency encompasses ratings ranging from 10 to 40 percent. A 40 percent rating contemplates a daytime voiding interval less than one hour, or awakening to void five or more times per night. A 20 percent rating contemplates daytime voiding interval between one and two hours, or awakening to void three to four times per night. A 10 percent rating contemplates daytime voiding interval between two and three hours, or awakening to void two times per night. Id. Obstructed voiding warrants ratings ranging from noncompensable to 30 percent. A 30 percent rating contemplates urinary retention requiring intermittent or continuous catheterization. A 10 percent rating contemplates marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: (1) post-void residuals greater than 150 cubic centimeters (cc's); (2) uroflowmetry; markedly diminished peak flow rate (less than 10 cc's per second); (3) recurrent urinary tract infections secondary to obstruction; (4) stricture disease requiring periodic dilatation every two to three months. A noncompensable rating contemplates obstructive symptomatology with or without stricture disease requiring dilatation one to two times per year. Id. Other potentially applicable criteria is the criteria for urinary tract infection which allows for rating under the criteria for renal dysfunction if poor renal function is present. A 30 percent rating is warranted for recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. A 10 percent rating is warranted for long-term drug therapy, 1-2 hospitalizations per year and/or requiring intermittent intensive management. 38 C.F.R. Part 4, § 4.115a (2009). The Veteran was provided a VA genitourinary evaluation in October 2004. The examiner noted that the claims file was not available. The diagnosis was Reiter's syndrome with history of recurrent urethritis, last episode two years earlier, asymptomatic now. Private treatment records from Dr. Garcia dated from February 2006 to July 2009 reveal that the Veteran complained in February 2009 that he had intermittent urge incontinence to the point that he fashioned a "condom type apparatus" while he is working to prevent getting his clothes wet. He also said that he had to get up from one to five times a night to urinate. He said in April 2009 that his urinary symptoms had greatly improved. The Veteran denied nocturia when seen in June 2009, and the diagnosis was benign prostatic hypertrophy, currently controlled with Flomax and Detrol. The Veteran said in July 2009 that he had discontinued Flomax. He said that he occasionally had some episodes of urgency and incontinence. The Veteran testified in February 2008 that his urinary condition was controlled on Flomax. The Veteran complained on VA genitourinary evaluation in March 2010 of intermittent discharge and burning on urination. He did not have urgency, straining to urinate, or urine retention; he did complain of hesitancy/difficulty starting stream and a weak or intermittent stream. There was no history of urinary tract infections, obstructed voiding or leakage. The Veteran said that his daytime voiding interval was one to two hours and he voided once a night. Bladder examination was normal. The diagnosis was non-specific urethritis; no symptoms or signs of pathology on examination. It was noted that the Veteran's urethritis did not significantly affect his employment or daily activities. Although there are two references in 2009 to occasional incontinence, there is no evidence that the Veteran has required the wearing of absorbent materials. He reported on examination in March 2010 that he did not have urgency or a history of leakage. Consequently, an evaluation based on urinary leakage is not appropriate. Although the Veteran reported obstructive symptoms on VA examination in March 2010, the medical evidence does not show any of the marked obstructive symptomatology required for a compensable rating, such as urinary tract infections or strictures. Consequently, the Veteran's condition is rated for frequency. A compensable evaluation is also not warranted for frequency, as it was reported on evaluation in October 2004 that the condition was asymptomatic. Prior to VA evaluation in March 2010, there is only one reference to getting up more than one a night to void, in February 2009, but subsequent references in 2009 indicate that the condition had improved with only occasional problems. However, when evaluated by VA on March 8, 2010, the Veteran reported daytime voiding every one to two hours. Although the VA examiner found no abnormal finding in March 2010, and noted that the Veteran's urethritis did not affect his employment or daily activities, the Board notes that the relevant schedular criteria is primarily based on a veteran's subjective history. By extending the benefit of the doubt to the Veteran, as required by law, the Board finds that a rating of 20 percent is warranted beginning March 8, 2010 for urethritis based on complaints of daytime voiding every one to two hours. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Conclusion Ordinarily, the Schedule will apply unless there are exceptional or unusual factors, which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular rating is warranted upon a finding that "the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2009). The schedular evaluations in this case is not inadequate. Ratings in excess of those assigned are provided for certain manifestations of each of the service-connected disorders at issue, but the medical evidence reflects that those manifestations are not present in this case. See 38 C.F.R. § 4.1 (2009). The medical findings do not indicate that the Veteran's low back, hypertension, or urethritis caused "marked" interference with employment. In fact, the Veteran had flexion of the low back to 80 degrees in March 2010, his hypertension was considered under good control, and it was noted in March 2010 that the Veteran's urethritis did not affect his employment or daily activities. There is also no evidence of frequent periods of hospitalization due to any of these service-connected disorders. Consequently, the Board finds that the criteria for referral for the assignment of an extraschedular evaluation pursuant to 38 C.F.R. § 3.321(b)(1) are not met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). In reaching the above decision, the Board considered the doctrine of reasonable doubt; however, other than the claim for an increased evaluation for urethritis beginning March 8, 2010, the preponderance of the evidence is against each of the claims on appeal and the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for bilateral hearing loss is denied. An evaluation in excess of 20 percent for a low back is denied. A compensable evaluation from April 30, 2003 to March 7, 2007 and to an evaluation in excess of 10 percent beginning March 8, 2007 for hypertension is denied. A compensable evaluation for urethritis from April 30, 2003 to March 7, 2007 is denied. A 20 percent rating is granted for urethritis beginning March 8, 2010 subject to the controlling regulations applicable to the payment of monetary benefits. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs