Citation Nr: 1209847 Decision Date: 03/15/12 Archive Date: 03/28/12 DOCKET NO. 09-04 231 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin 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: Wisconsin Department of Veterans Affairs ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1956 to December 1976. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from an April 2008 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. In September 2011, the Board remanded the issue on appeal for further examination. That development has been completed. FINDING OF FACT The evidence demonstrates it is likely that the Veteran's erectile dysfunction is related to his service-connected PTSD. CONCLUSION OF LAW The criteria for a grant of service connection for erectile dysfunction, to include as secondary to the Veteran's service-connected PTSD, have been met. 38 U.S.C.A. §§ 1110, 1131, 1133, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.303, 3.310 (2011). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). In light of the favorable disposition, a discussion as to whether VA's duties to notify and assist the appellant have been satisfied is not required. The Board finds that no further notification or assistance is necessary, and deciding the appeal at this time is not prejudicial to the Veteran. II. Service Connection Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To establish service connection, there must be: (1) a medical diagnosis of a current disability; (2) medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999) (citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996)). Service connection may also be established on a secondary basis for disability which is proximately due to, or the result of, a service connected disease or injury. See 38 C.F.R. § 3.310(a) ( 2011). The Court has construed this provision as entailing "any additional impairment of earning capacity resulting from an already service connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service connected condition." See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for the evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the Veteran. The Veteran seeks service connection for erectile dysfunction as secondary to his PTSD. The Veteran has claimed that medication taken for his service-connected PTSD is causing erectile dysfunction. He has stated that his erectile function declined when he began using Wellbutrin for his PTSD. Due to the favorable decision in the case below, a discussion for a grant of service connection on a direct basis is not necessary. 38 C.F.R. § 3.303. The Veteran was first afforded a VA examination in March 2008. The examiner noted that the Veteran's private physician saw him in May 2006 for an evaluation, where the Veteran complained of decreased libido and erectile dysfunction of one year's duration. The Veteran was diagnosed with hypogonadism. The Veteran reported receiving medication for ED in January 2008. The Veteran claimed that in 2003, when he was placed on Effexor due to increased depression when his son was going to Iraq, he began noticing ED problems. The Veteran reported multiple medication changes for his depression and ED. He stated that he was ultimately put on Wellbutrin, and continued to have ED problems. The Veteran reported all of his medical conditions and the medications he was taking for them. After examining the Veteran, the VA examiner diagnosed him with chronic erectile dysfunction. The examiner stated that the Veteran was on antihypertensive medication as well as an antidepressant, both types which could contribute to his ED. The examiner stated that the Veteran was diagnosed with hypogonadism, which will lead to ED. Moreover, the examiner stated that based on these multiple causative factors, he could not determine if the Veteran's ED was caused by or aggravated by his medication taken for his service-connected anxiety with depression, without resorting to mere speculation. In April 2011, the Board requested a pharmacologist/pharmacist medical opinion through a Veterans Heath Administration (VHA) directive to determine whether the medication the Veteran was prescribed for his service-connected PTSD caused erectile dysfunction. A May 2011 medical opinion was obtained from a Chief of Pharmacy. The pharmacist discussed the side effects of medication listed in the Veteran's medical records, to include Wellbutrin and Toprol XL. She reported that Bupropion (Wellbutrin) was often prescribed for patients concerned with the sexual side effects of antidepressant drugs. Additionally, she reported that incidence of sexual dysfunction among antidepressants can be high, but Bupropion is one of the few antidepressants that have a low incidence of sexual dysfunction. The doctor stated that among the other medications the Veteran was taking that may cause ED, the antihypertensive beta blocker metoprolol extended-release was a possibility. The Veteran was afforded another VA examination in September 2011. The examiner noted that the Veteran had current diagnoses of erectile dysfunction, vasectomy, and hypogonadotropic hypogonadism. The examiner documented a detailed history of the Veteran's medical conditions and medications taken. The examiner stated that the Veteran had erectile dysfunction, with etiologies of hypogonadism, hypertension, untreated hypothyroidism, and antidepressant medication. The examiner concluded that after reviewing the c-file, the medical records, and having examined the Veteran, it was his opinion that the Veteran's ED was less likely as not caused by or a result of his PTSD antidepressant therapy. Additionally, the examiner stated that the Veteran had several potential causes of his ED: hypogonadism with testicular atrophy now on hormone replacement therapy, a lengthy history of hypertension on treatment, untreated hypothyroidism, older age, and antidepressant therapy for his PTSD. Furthermore, the examiner stated that while all are likely contributing in a small way to his ED, although it was his opinion that the Veteran's hypogonadism with testicular atrophy most likely had been the significant contributor to his ED. In light of the evidence, the Veteran is entitled to service connection for erectile dysfunction secondary to his service-connected PTSD antidepressant therapy. The Veteran's private physician, and March 2008 and September 2011 VA examiners diagnosed the Veteran with erectile dysfunction. The March 2008 VA examiner stated that the Veteran was on antihypertensive medication as well as an antidepressant, both types which could contribute to his ED. Additionally, while the September 2011 VA examiner stated that the Veteran's ED was less likely as not caused by or a result of his PTSD antidepressant therapy, he also listed the Veteran's PTSD antidepressant treatment as an etiology and a contributing factor to his ED. Therefore the preponderance of the evidence is for the Veteran's claim. Because the preponderance of the evidence is for the claim, the benefit of the doubt rule applies and service connection for the Veteran's erectile dysfunction as secondary to his service-connected PTSD will be granted. 38 U.S.C.A. § 5107(b); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected posttraumatic stress disorder, is granted. ____________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs