Citation Nr: 1237800 Decision Date: 11/05/12 Archive Date: 11/09/12 DOCKET NO. 10-24 983 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Sioux Falls, South Dakota THE ISSUE Entitlement to service connection for erectile dysfunction. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD Jarrette A. Marley, Associate Counsel INTRODUCTION The Veteran had active duty service from March 1966 to February 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran's notice of disagreement was received in March 2010. A statement of the case was issued in June 2010. A substantive Appeal was received in June 2010. The Veteran withdrew his request for a hearing before the Board in May 2011. As such, there are no outstanding hearing requests of record. 38 C.F.R. § 20.704(e). FINDING OF FACT There is a state of equipoise on the question of whether or not the Veteran's erectile dysfunction is a complication of medications he takes for his service-connected posttraumatic stress disorder. CONCLUSION OF LAW Secondary service connection for erectile dysfunction is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Analysis The Veteran is seeking entitlement to service connection for erectile dysfunction. Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury or disease in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a nonservice-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. When all of the evidence is assembled, 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran's service treatment records are silent regarding erectile dysfunction. Historically, an April 1991 Board decision granted service connection for posttraumatic stress disorder (PTSD). August and October 1991 letters from Thomas L. Price, M.S., noted the Veteran was receiving psychological testing and intensive individual and family therapy. It was indicated that the Veteran was suffering from numerous emotional and interpersonal problems, including significant problems with intimacy and interpersonal relations. On October 1991 VA psychological evaluation (regarding PTSD), the examiner noted that there was some fairly unusual sexual concerns mentioned by the Veteran (unexplained). An August 2003 VA treatment record noted his complaint of significant problems with erections, although he still has a very good libido. A February 2006 VA mental health telephone report noted the Veteran's complaint that his sex life has been non-existent for 14 years due to a misunderstanding with his wife. However, it was noted he had problems with erectile functioning prior to the misunderstanding. A September 2007 United Clinic private treatment record listed his mental health history included male erectile disorder. A November 2007 record included an assessment of erectile dysfunction. An October 2009 VA primary care report noted the Veteran's complaint that his erectile dysfunction started after taking psychiatric medication, and that it has not improved. A November 2009 VA treatment letter from Dr. Donna M. Small reported that as discussed in October 2009, she believed his erectile dysfunction was secondary to his psychiatry medication. The instant claim for service connection for erectile dysfunction was filed in December 2009, claimed as secondary to his service-connected PTSD. On February 2010 VA examination, the Veteran reported the last time he had sexual intercourse was 20 years prior, and that sexual relations are not a high priority for him. He further reported he has never mentioned erectile dysfunction to his care providers and that he has never asked to have his medication changed because of the reported and alleged sexual side effects. The examiner opined that it could not be determined whether the Veteran's erectile dysfunction was secondary to his psychotropic medication, and should be referred to his psychiatrist. The examiner found noteworthy the Veteran has never felt that his erectile dysfunction has impacted his emotional or interpersonal functioning, and that it has never bothered him enough to bring the problem up to a medical care provider. On May 2010 VA examination, it was reported that review of the Veteran's claims file revealed no annotation of erectile dysfunction until May 2009 in problem lists. In addition, none of the mental health care or primary care notes have ever mentioned it. The Veteran did report the problem to his primary care physician in October 2009. Shortly after this report, the Veteran filed a claim for erectile dysfunction as secondary to PTSD medications. The examiner opined that because there are many documented possible causes for erectile dysfunction in this Veteran, such as age, usage of opioids, emotional problems with significant other, benign prostatic hypertrophy, tobacco usage, and a mood disorder, it was less likely than not that any erectile dysfunction was related to medication for PTSD. A July 2010 Dr. Reid Holkesvik private treatment letter opined that the Veteran suffers from erectile dysfunction, which is very likely as least in part caused by psychotropic drugs used to treat his chronic paranoid schizophrenia, and also in part from hypotestosteronism, for which he is on replacement therapy. A September 2010 Dr. Reid Holkesvik private treatment letter indicated the July 2010 letter was incorrectly or at least incompletely stated, as psychotropic medications which the Veteran takes for his PTSD are also a cause for his erectile dysfunction. The medications at issue are Trazodone and Clonazepam, which it was assumed are prescribed more for symptoms of PTSD than for schizophrenia, for which Risperidone is primarily prescribed. On October 2010 VA examination, it was noted that erectile dysfunction was first diagnosed in November 2009 after his complaint of such in October 2009. His current medications include Trazodone, which is for depression, Clonazepam, which can be used for schizophrenia, and Risperidone, also for depression. Review of his medications revealed no mention of erectile dysfunction as a significant side effect or problem except for in relation to Clonazepam, which indicated delayed ejaculation and impotence could be noted. The Veteran has been on Clonazepam (or Klonopin) since early treatment with his diagnosis of schizophrenia. While it is sometimes used in PTSD patients, in the Veteran's case it was initially started for his chronic paranoid schizophrenia. After a review of the records and findings at the time of the examination, the examiner opined it was less likely than not that the other medications for his PTSD were related to his erectile dysfunction, in part because, he did not mention a problem for erectile dysfunction until 2009. His erectile dysfunction is more likely related to his Klonopin at the present time and to his endocrine problem with low testosterone which is currently being treated. At the outset, the Board notes that whether or not the Veteran can maintain an erection is something capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The record reflects that the Veteran has service-connected PTSD. The remaining question is whether or not he has erectile dysfunction that was caused by or aggravated by such disability. The Board notes that the Veteran has been afforded VA examinations regarding this matter in February, May and October 2010. The Board finds little probative value in these examination reports. Specifically, the February 2010 VA examiner did not provide an opinion that addressed the issue. The May and October 2010 VA examination reports appear to be based, at least in part, on inaccurate factual premises. In particular, the opinions indicate that there was no complaint or annotation of erectile dysfunction in the Veteran's claims file until 2009. However, as noted above, the Veteran complained of problems with erections/erectile dysfunction in August 2003 and February 2006. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (finding that a physician's opinion based on an inaccurate factual premise has no probative value); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303 (2008) (the relevant focus is not on whether the clinician had access to the claims file, but instead on whether the clinician was "informed of the relevant facts" in rendering a medical opinion). The Board is left then with various medical letters, VA and private, that relate the Veteran's erectile dysfunction to his medication for his PTSD. Although it is not entirely clear, the Board finds that the evidence is at least in a state of equipoise whether the Veteran's erectile dysfunction is medically causally related to his service-connected PTSD. Accordingly, the Board finds that service connection for erectile dysfunction is warranted secondary to the Veteran's service-connected PTSD. 38 U.S.C.A. § 5107. In closing, there is no need to undertake any review of compliance with the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations in this case since there is no detriment to the Veteran as a result of any VCAA deficiency in view of the fact that the full benefit sought by the Veteran is being granted by this decision of the Board. See generally 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). By a letter dated in December 2009, the Veteran was furnished notice of the matter of assigning a disability evaluation and an effective date. He will have the opportunity to initiate an appeal from these 'downstream' issues if he disagrees with the determinations which will be made by the RO in giving effect to the Board's grant of service connection. ORDER Entitlement to service connection for erectile dysfunction is warranted. The appeal is granted. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs