Citation Nr: 1237002 Decision Date: 10/25/12 Archive Date: 11/08/12 DOCKET NO. 09-49 066 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES Entitlement to service connection for erectile dysfunction, claimed as secondary to medications taken for service-connected psychiatric disability. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD S. Higgs, Counsel INTRODUCTION The Veteran served on active duty from October 1972 to July 1978 and from November 1990 to May 1991. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in June 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The Veteran provided testimony at a July 2012 hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND The Veteran claims that, contrary to a May 2008 VA examination addendum opinion, his psychiatric medication clonazepam has been associated with erectile dysfunction. He has submitted evidence indicating he takes clonazepam and prescription form information indicating that clonazepam may affect sex drive. In addition, in reviewing medical information offered to the public by the Federal Government, the Board notes the following abstract of a study conducted by or in association with VA: Anxiety. 1994-1995;1(5):233-6. clonazepam-related sexual dysfunction in male veterans with PTSD. Fossey MD, Hamner MB. Source Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401, USA. Abstract Medication-induced sexual dysfunction can significantly interfere with patients' quality of life and lead to poor compliance. This retrospective study examined the records of 100 male veterans with post-traumatic stress disorder (PTSD) selected in alphabetical order from an active treatment file of 230 patients. Forty-two patients had received clonazepam (mean maximum dose: 3.4 +/- 1.6 mg/day) at some point during their treatment. Of these, 18 (42.9%) complained of significant sexual dysfunction (primarily erectile dysfunction). Eighty-four patients received diazepam (mean maximum dose: 52.1 +/- 29.7 mg/day), nine received alprazolam (mean maximum dose: 5.2 +/- 2.8 mg/day) and eight received lorazepam (mean maximum dose: 3.8 +/- 2.4 mg/day). None of these patients complained of sexual dysfunction during treatment with these three other benzodiazepines. Our findings suggest that benzodiazepines, particularly clonazepam in the current study, can be a cause of sexual dysfunction in many male patients. Prospective studies comparing the overall clinical utility of various benzodiazepines are indicated in this and other clinic populations. PMID: 9160580 [PubMed - indexed for MEDLINE] (Emphases added.) This information may be accessed on the Internet via this link: http://www.ncbi.nlm.nih.gov/pubmed/9160580 Nevertheless, medical literature evidence is generally not specific enough to establish a nexus in a particular case. See Sacks v. West, 11 Vet. App. 314 (1998) (holding that treatise materials are generally not specific enough to show nexus); Herlehy v. Brown, 4 Vet. App. 122 (1993) (in general, medical opinions directed at specific patients are more probative than medical treatises). Further, the Board notes that the claims file was not made available at the May 2008 VA examination, and that the initial report of examination claimed to be based on review of the Veteran's medical records but did not note that the Veteran received clonazepam. A new examination and opinion, from a clinician with more appropriate or greater medical expertise, and based on a more complete review of the record and the medical literature, is required. See 38 C.F.R. § 4.2 (VA examinations-corrective action.) The new medical opinion must include consideration of whether the Veteran's erectile dysfunction may be caused or aggravated by the Veteran's service-connected psychiatric disorder, rated as 100 percent disabling from August 1996 forward, or by psychiatric medications. See 38 C.F.R. § 3.310 (disabilities that are proximately due to, or aggravated by, service-connected disease or injury). Also, there are indications in the claims file that the Veteran may be in receipt of Social Security Administration (SSA) disability benefits. However, there is as of yet no indication that the SSA records may be relevant to the Veteran's claim. Thus, it is not clear whether such records would need to be obtained in this matter. See generally, Golz v. Shinseki, 530 F.3d 1317 (holding that under the facts of a specific case the Court of Appeals for Veterans Claims correctly determined that Veteran's medical records used to determine his eligibility for SSA benefits were not relevant to a VA determination). Additionally, any additional identified relevant medical evidence must be sought for association with the claims file. See 38 U.S.C.A. § 5103A(a)-(c). Accordingly, the case is REMANDED for the following action: 1. Request the Veteran to identify all records of VA and non-VA health care providers who may have further medical evidence relevant to his claim. * The records sought must include any additional relevant medical records of VA treatment not associated with the claims file. * After obtaining any appropriate authorizations for release of medical information, the RO/AMC must seek to obtain any potentially relevant and available records that have not been previously received from each health care provider the Veteran identifies. * The Veteran must also be advised that with respect to private medical evidence he may alternatively obtain the records on his own and submit them to the RO/AMC. 2. The Veteran must be contacted and asked if he has applied for or receives Social Security Administration (SSA) disability benefits, and if so, whether there is a reasonable possibility that the SSA disability records would be relevant to adjudication of his claim for service connection for erectile dysfunction. If so, the SSA disability records must be sought for association with the Veteran's claims file. 3. Once all available medical records have been received, arrange for a VA examination with a PHYSICIAN specializing in an appropriate field of medicine. The purpose of the examination is to determine whether the Veteran's erectile dysfunction is caused or aggravated by the Veteran's service-connected psychiatric disability or by medications he takes for service-connected psychiatric disability. The following considerations will govern the examination: * The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials in any report generated as a result of this remand. * The examiner must take a complete history from the Veteran as to the nature and onset of his erectile dysfunction. * If there is a medical basis to support or doubt the history provided by the Veteran, the examiner must state this, with a fully reasoned explanation. * The examiner must review the abstract of a study entitled "clonazepam-related sexual dysfunction in male veterans with PTSD," apparently conducted by or in associated with the Department of Veterans Affairs, set forth in the body of this remand, above, and at the following web address: http://www.ncbi.nlm.nih.gov/pubmed/9160580 The study contains the following language: "Our findings suggest that benzodiazepines, particularly clonazepam in the current study, can be a cause of sexual dysfunction in many male patients." * The examiner must conduct any additional review of the medical literature necessary for providing the opinions requested in this matter. * The examiner must provide an opinion as to whether the Veteran's erectile dysfunction is caused or aggravated (chronically worsened) by his service-connected psychiatric disability, rated as 100 percent disabling from August 1996 forward. * The examiner must provide an opinion as to whether the Veteran's erectile dysfunction is caused or aggravated (chronically worsened) by medications, including clonazepam, which he receives for service-connected psychiatric disability. * In all conclusions, the examiner must identify and explain the medical basis or bases, with identification of the relevant evidence of record. * The examiner must provide a FULLY REASONED EXPLANATION for his or her opinions, based on his or her clinical experience, medical expertise, established medical principles, and review of pertinent medical literature. 4. Readjudicate the issue on appeal. If the benefit sought remains denied, provide the Veteran and his representative a supplemental statement of the case and an appropriate period of time for response. Thereafter, subject to current appellate procedure, the case must be returned to the Board for further consideration, if otherwise in order. No action is required of the Veteran until he is otherwise notified by the RO/AMC. By this action, the Board intimates no opinion, legal or factual, as to any ultimate disposition warranted in this case. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). _________________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2011).