Citation Nr: 1011006 Decision Date: 03/24/10 Archive Date: 03/31/10 DOCKET NO. 07-17 460 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hypertension, claimed as secondary to service-connected PTSD. 3. Entitlement to service connection for erectile dysfunction, claimed as secondary to service-connected disability. ATTORNEY FOR THE BOARD A. Nigam, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1965 to May 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision and a June 2008 rating decision of the RO. FINDINGS OF FACT 1. All relevant evidence necessary for the equitable disposition of the issues addressed in this decision was obtained. 2. The service-connected PTSD is currently manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood and an inability to establish and maintain effective work and social relationships; total occupational and social impairment is not demonstrated. 3. The currently demonstrated hypertension is shown as likely as not to have been aggravated by the service- connected PTSD. 4. The currently demonstrated loss of use of a creative organ due to erectile dysfunction is shown as likely as not to have been caused by the service-connected residuals of prostate cancer. CONCLUSIONS OF LAW 1. The criteria for the assignment of an evaluation in excess of 70 percent for the service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.130 including Diagnostic Code (DC) 9411 (2009). 2. By extending the benefit of the doubt to the Veteran, his disability manifested by hypertension is proximately due to or the result of service-connected disability. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.310 (2009); Allen v. Brown, 7 Vet. App. 439 (1995). 3. By extending the benefit of the doubt to the Veteran, his disability manifested by erectile dysfunction is proximately due to or the result of service-connected disability. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.310 (2009); Allen v. Brown, 7 Vet. App. 439 (1995). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2009)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2009). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), the United States Court of Appeals for Veterans Claims (Court) found that, at a minimum, adequate VCAA notice requires that VA notify the claimant that, to substantiate such a claim: (1) the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life; (2) if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant; (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and (4) the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. In Vazquez-Flores, the Court further indicated that consideration was warranted for whether there existed subsequent VA action that served to render any pre- adjudicatory notice error non-prejudicial. In a September 4, 2009 decision, the United States Court of Appeals for the Federal Circuit (Federal Circuit) vacated the Court's decision in Vazquez-Flores and held that, in accordance with its decision in Paralyzed Veterans of Am. V. Sec'y of Veterans Affairs, 345 F.3d 1334 (Fed. Cir. 2003), and Wilson v. Mansfield, VA Form 7-506, Notice of Authorization of Training and Subsistence Allowance, F.3d 1055 (Fed. Cir. 2007), such specificity in notice as the Court had required was not necessary. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. Sept. 4, 2009). Specifically, the Federal Circuit held that Wilson and Paralyzed Veterans eliminated the requirement for VA to provide veteran-specific notice, without altering the requirement that the notice be claim-specific. Id. Hence, in light of the Federal Circuit's decision in Vazquez-Flores, VA need only provide adequate generic notice in compliance with section 5103 (a). In the present case, in letters dated in May 2005, September 2005, February 2008, and August 2008, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate the claims, as well as what information and evidence must be submitted by the Veteran and the types of evidence that will be obtained by VA. The February 2008 notice letter addressed how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. Further, the August 2008 letter addressed aspects of the notice requirements of Vazquez-Flores, and contained examples of types of medical and lay evidence that are relevant to establishing entitlement to increased compensation. These claims were last adjudicated, via a Statement of the Case (SOC), issued in January 2009, and a Supplemental SOC (SSOC), issued in April 2009. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file includes private and VA treatment records, and VA examination reports. Also of record and considered in connection with the appeal are written statements submitted by the Veteran. As discussed, the Veteran was notified and aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process, identifying and submitting pertinent medical and lay evidence. Thus, the Veteran has been provided with a meaningful opportunity to participate in the claims process and has done so. Any defect in the sequence of events or content of the notice is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, to the extent that the action taken herein below is favorable to the Veteran, any such error is harmless and does not prohibit consideration of this matter on the merits. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). General Legal Criteria Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that 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 following analysis in this decision is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In exceptional cases where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent period of hospitalizations as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2009). PTSD The Veteran's PTSD is currently evaluated as 70 percent disabling under 38 C.F.R. § 4.130, DC and 9411 (2009). DC 9411 provides: 100 percent: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance or minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name; 70 percent: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships; Global Assessment of Functioning (GAF) GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. See 38 C.F.R. § 4.130 [incorporating by reference the VA's adoption of the DSM-IV, for rating purposes] (2009). Service Connection In general, service connection may be granted for disability resulting from disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. § 1110. Service connection may also be established for disease diagnosed after discharge from service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2009). To establish a service connection for an injury, a veteran is required to show (1) medical evidence of a current disability, (2) medical or lay evidence of in-service incurrence or aggravation of an injury, and (3) medical evidence of a nexus between the claimed in-service injury and the present disability. Dalton v. Nicholson, 21 Vet. App. 23, 36 (2007). In cases where the veteran cannot establish some of these elements, a veteran can instead establish continuity of symptomatology. 38 C.F.R. § 3.303(b); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). To establish continuity of symptomatology, the a veteran is required to show "(1) that a condition was 'noted' during service, (2) evidence of postservice continuity of the same symptomatology, and (3) medical or lay evidence of a nexus between the present disability and the postservice symptomatology." Barr, 21 Vet. App. at 307. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Secondary service connection shall be awarded when a disability "is proximately due to or the result of a service- connected disease or injury." 38 C.F.R. § 3.310(a). Also, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. See 71 Fed. Reg. 52744-52747 (Sept. 7, 2006) (to be codified at 38 C.F.R. § 3.310(b)); Libertine v. Brown, 9 Vet. App. 521, 522 (1996); see also Reiber v. Brown, 7 Vet. App. 513, 515-16 (1995); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Effective on October 10, 2006, 38 C.F.R. § 3.310 was amended to implement the holding in Allen v. Brown, 7 Vet. App. 439 (1995) for secondary service connection on the basis of the aggravation of a nonservice-connected disorder by service- connected disability. See 71 Fed. Reg. 52744 (2006). The amendment essentially codifies Allen with language that requires that a baseline level of severity of the nonservice- connected disease or injury must be established by medical evidence created before the onset of aggravation. As to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service- connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the claimed disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. Standard of Review 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. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Increased Rating for PTSD By way of background, in a November 2002 rating decision, the RO granted service connection for PTSD and assigned a 30 percent rating, effective on August 16, 2000. In a June 2003 rating decision the RO increased the rating to 50 percent, effective on February 10, 2003. In August 2003, the RO granted an increased the rating to 70 percent, effective on July 28, 2003. Notably, a rating decision, dated in December 2003 and issued in January 2004, granted a total compensation rating based on individual unemployability (TDIU), effective on August 13, 2003. The Veteran contends that his PTSD warrants an increased rating due to symptoms that include markedly impaired concentration, grossly impaired memory, flattened affect, poor maintenance of minimal personal hygiene, mood blunted, bland, and severely depressed, impaired judgment, sleep pattern disturbance due to nightmares, isolation, severe interpersonal relationship problems and unemployability which is permanent in nature. The private and VA treatment records, dated from January 2007 to June 2008, reflected symptoms of markedly impaired concentration, grossly impaired memory, flattened affect, poor maintenance of minimal personal hygiene, mood blunted, bland, and severely depressed, impaired judgment, sleep pattern disturbance due to nightmares, isolation, severe interpersonal relationship problems and unemployability, and GAF scores of 30. In conjunction with the current appeal, the Veteran underwent a VA PTSD examination in February 2008. He reported receiving treatment at the Raleigh Vet Center since September 2000 for his PTSD, and with a private psychiatrist since 2001, but denied hospitalization for a mental disorder. The examination findings included clean though not completely shaven in physical appearance, unremarkable psychomotor activity and speech, cooperative attitude, appropriate affect, and "not too good mood." The examiner observed that attention was intact, orientation was intact to person, place and time, thought process and content were unremarkable, judgment was good, intelligence was average, and insight was good as the Veteran understood that he has a problem. The Veteran endorsed symptoms of chronic sleep impairment, but denied hallucinations, panic attacks, episodes of violence, homicidal ideation, and suicidal ideation. The examiner noted that the Veteran had inappropriate behavior in the form of reclusive, antisocial behaviors that have reportedly gotten worse over the last 8 to 9 months. Further, the Veteran had obsessive and ritualistic behavior such as checking to make sure doors are secure after he leaves, 2 or 3 times, and at night before bed. The Veteran denied impaired impulse control but was observed to experience difficulty in maintaining minimal personal hygiene. His remote memory was deemed normal, but recent and immediate memory was deemed mildly impaired. The report shows that PTSD symptoms included chronic, recurrent and intrusive distressing recollections, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, restricted range of affect, difficulty falling or staying asleep, and exaggerated startle response. The Veteran indicated that these PTSD symptoms had led him to "be real cautious," and that his social contact and relationships were primarily at the Vet Center and church, which he attended about twice a month. He went to the movies once every 3 weeks and talked to his brothers and sisters once or twice a week. The Veteran was diagnosed with chronic PTSD and assigned a GAF score of 49. The examiner noted that the changes in functional status and quality of life since the last examination were in the areas of routine responsibilities of self-care, family role functioning, social/interpersonal relationships, and recreation/leisure pursuits. The examiner concluded that there was no total occupational and social impairment due to PTSD signs and symptoms; however, PTSD signs and symptoms resulted in deficiencies in the areas of judgment, thinking, family relations, work, and mood, and there was reduced reliability and productivity due to his PTSD symptoms. The Board has reviewed the aforementioned evidence but finds that the criteria for an evaluation in excess of 70 percent have not been met. Although private treatment records reflect that the Veteran has consistently been assigned a GAF score of 30, which under the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM- IV) is reflective of behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas, the medical findings for the relevant time period would suggest otherwise. In fact, at no point during the time on appeal has the Veteran complained of any hallucinations, persistent delusions, persistent suicidal or homicidal ideation, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. The objective findings on the February 2008 VA PTSD examination, show a GAF score of 49, reflective of serious symptoms, or any serious impairment in social, occupational or school functioning. The Board finds that the symptoms of inappropriate behavior in the form of reclusive, antisocial behaviors, obsessive and ritualistic behavior such as checking to make sure doors are secure, and difficulty in maintaining minimal personal hygiene do not amount to the gross impairment in thought processes or communication necessary to prove total occupational and social impairment. Further, the VA examiner opined that the Veteran's symptoms did not cause him to experience total occupational and social impairment. Moreover, as noted, the GAF scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the evaluation issue; rather, they must be considered in light of the actual symptoms of the Veteran's disorder (which here, provide the primary basis for the initial rating assigned). See 38 C.F.R. § 4.126(a). The Board notes that the United States Court of Appeals for the Federal Circuit (Federal Circuit) has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Overall, the evidence does not support an evaluation in excess of 70 percent for PTSD, and the claim for this benefit must be denied. 38 C.F.R. §§ 4.3, 4.7. The Board has considered the provisions of 38 C.F.R. § 3.321(b)(1), but finds no evidence that the Veteran's service-connected disability has caused marked interference with employment beyond that contemplated by the schedule for rating disabilities, necessitated frequent periods of hospitalization, or otherwise renders impractical the application of the regular schedular standards utilized to evaluate the severity of this disability. The Board notes that the Veteran has already been granted a TDIU rating for his service-connected PTSD. The regular schedular rating criteria specifically contemplate the Veteran's complaints or clinical findings that include suicidal ideation and hospitalization. In the absence of such factors, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected disability under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Service connection for hypertension, claimed as secondary to PTSD The Veteran contends that his current hypertension is the result of his service-connected PTSD. Specifically, he asserts that his PTSD causes him to have high blood pressure. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim of service connection for hypertension claimed as secondary to PTSD. Additionally, the medical evidence does not show that hypertension warrants service connection on a direct basis; nor is it contended or shown by medical evidence that hypertension is related to any other service-connected disability. Notably, the service treatment records are negative for diagnosis of or treatment for hypertension. Moreover, findings of hypertension were not indicated in treatment records until many years after service. This is strong evidence against a finding of any continuity of symptomatology and against the claim for service connection. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000). The VA and private treatment records, dated from September 2002 to June 2007, reveal findings of and treatment for hypertension. Significantly, a June 2005 private treatment note reflects an opinion that the Veteran's current hypertension was the direct result of his PTSD. In conjunction with the current appeal the Veteran went a VA hypertension examination in March 2009. Here, the examiner noted 1996 at the date of onset of the Veteran's hypertension. The Veteran reported that he had been taking blood pressure medication for several years that had stabilized his disorder. The Veteran was diagnosed with essential hypertension, without hypertensive heart disease. The examiner opined that the hypertension was not due to or a result of the service- connected PTSD. The examiner explained that reports based upon the Vietnam Era Twins Study (VETS) database did not support the contention that PTSD caused or chronically aggravated hypertension, and the Veteran is not documented to be in a chronic hyperadrenergic state and was not observed to be so at the time of the examination. The Board has carefully reviewed the record and finds the evidence to be in relative in equipoise in showing that the current hypertension as likely as not was aggravated by the service-connected PTSD. Accordingly, in resolving all reasonable doubt in the Veteran's favor, for the reasons stated above, the secondary service-connection for hypertension is warranted. Service connection for erectile dysfunction, claimed as secondary to PTSD The Veteran asserts that his current erectile dysfunction is the result of his service-connected disability. Initially, he does not argue nor does the evidence show that the claimed erectile dysfunction was present in service or for many years thereafter. The VA and private treatment records, dated from April 2005 to June 2007, show findings of erectile dysfunction treated with a trial of Viagra. Specifically, VA treatment records in June 2005 and June 2006 reflect that the Viagra use yielded good results. Significantly, the April 2005 and June 2005 private physician statements include opinions that the service-connected PTSD was causing his erectile dysfunction disorder. The Veteran underwent a VA examination in January 2006 and described being able to perform vaginal penetration or ejaculation sometimes with medication and sometimes not. He denied having symptoms of lethargy, weakness, anorexia, frequency urinating or incontinence. The examiner noted that the Veteran developed erectile dysfunction in 1995 and had tried medication in the past, to include Levitra and Viagra. The examiner noted that the Veteran had not undergone trauma or surgery to his penis or testicles. The Veteran was diagnosed with erectile dysfunction. The examiner opined that it would be mere speculation to estimate what relationship existed between the Veteran's erectile dysfunction and his long-standing PTSD. A July 2006 VA treatment record shows that the Veteran underwent external beam radiation therapy for prostate cancer. A December 2006 VA radiation oncology note showed that the Veteran did not have erections and was diagnosed with erectile dysfunction for which he was prescribed Viagra that "[did not] work well for him in the past." A June 2007 VA treatment record revealed findings of erectile dysfunction that was not helped by Viagra or Levitra. During a July 2007 VA genitourinary examination, the Veteran reported urinating 4 to 5 times per day, and getting up 4 to 5 times per night. He denied experiencing lethargy, weakness, anorexia, weight loss, dysuria or hesitancy in urinating when he took his medication. The Veteran complained of incontinency of urine and used 5 to 6 adult diapers per day. He denied a history of surgery, urinary tract infections, renal colic, bladder stones, acute nephritis, hospitalizations in the past year for urinary tract disease, catheterizations, dilatations, or drainage procedures and was not on a special diet due to his prostate cancer. The Veteran had undergone treatment for malignancy with external beam radiation in September 2006. The examiner noted the Veteran had some degree of loss of male creative organ, since prior to 2004, preceding his diagnosis and subsequent treatment for prostate cancer. The Veteran indicated that Viagra worked for him prior to his treatment, and that it had been inefficacious since his treatment. Further, Levitra failed as well. The examiner opined that the loss of creative organ was felt to be neurovascular. The Veteran was incapable of erection adequate for vaginal penetration or ejaculation for which he has taken medication and received some counseling; but for which he had not used injections, implants or pumps. On examination, the prostatic bed was noted as being smooth without nodule or tenderness, and seminal vesicles were noted as non-palpable. The examiner observed that there was no fistula present, visible residuals of urinary disease present, or testicular atrophy present. Sensation and reflexes were absent and peripheral pulses were not assessed. The Veteran was diagnosed with prostate cancer with residuals of incontinence and diminished stream. The examiner opined that, based upon review of the medical records, erectile dysfunction existed prior to the Veteran's diagnosis and treatment of prostate cancer. However, the examiner noted that, since Viagra had been effective prior to his treatment and that the Viagra and Levitra no longer provided efficacy since the external beam radiation, the erectile dysfunction was as likely as not secondary to the external beam radiation therapy. The examiner concluded that the erectile dysfunction was not as likely as not secondary to any service-connected conditions. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the grant of service connection for erectile dysfunction claimed as secondary to service-connected PTSD. However, the July 2007 VA examiner attributed the actual loss of use to the external beam radiation therapy used to treat service- connected prostate cancer. On this record, the evidence, in the Board's opinion, is in relative equipoise in showing that the current erectile dysfunction manifested by loss of use of a creative organ as likely as not is due the radiation therapy used to treat the service-connected prostate cancer. In resolving all reasonable doubt in the Veteran's favor, secondary service connection for erectile dysfunction manifested by loss of use of a creative organ is warranted. ORDER An increased evaluation in excess of 70 percent for the service-connected PTSD is denied. Service connection for hypertension, as secondary to the service-connected PTSD, is granted. Service connection for erectile dysfunction manifested by loss of use of a creative organ, as secondary to the service- connected prostate cancer, is granted. ____________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs