Citation Nr: 1303148 Decision Date: 01/30/13 Archive Date: 02/05/13 DOCKET NO. 09-16 617 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for erectile dysfunction, including as secondary to service-connected type II diabetes mellitus (DMII), and/or residuals of a cervical spine injury. REPRESENTATION Veteran represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD Michael Wilson, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1967 to November 1969, including service in the Republic of Vietnam. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which, in relevant part denied the Veteran's claim for service connection for erectile dysfunction. The Board remanded this claim in July 2012 in order for the RO to schedule him for a hearing. Before the Veteran's requested hearing could be scheduled, however, the Veteran indicated in an August 2012 statement that he wished to withdraw his hearing request. See 38 C.F.R. § 20.704(e) (2012). FINDINGS OF FACT 1. Service connection is in effect for type II diabetes mellitus, and residuals of a cervical spine injury, status post laminectomy, with C3-6 involvement. 2. The Veteran's current erectile dysfunction is caused by his service-connected type II diabetes mellitus and residuals of a cervical spine injury. CONCLUSION OF LAW The criteria for entitlement to service connection for erectile dysfunction as secondary to service-connected type II diabetes mellitus and residuals of a cervical spine injury have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION In this decision, the Board grants entitlement to service connection for erectile dysfunction as secondary to his service-connected DMII and/or service-connected residuals of a cervical spine injury. As this represents a complete grant of the benefit sought on appeal, no discussion of VA's duty to notify and assist pursuant to the Veterans Claims Assistance Act of 2000, 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002), is necessary. I. Governing Law and Regulations Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). The second and third elements may be established by showing continuity of symptomatology. Service connection may be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2012). Service connection may be also granted on a secondary basis for a disability that is proximately due to or the result of an established service-connected disorder. See 38 C.F.R. § 3.310(a) (2012). A claim for secondary service connection generally requires competent evidence of a causal relationship between the service-connected disability and the non-service-connected disease or injury. See Jones (Wayne L.) v. Brown, 7 Vet. App. 134 (1994). There must be competent evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Similarly, any increase in severity of a non-service-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 non-service-connected disease, will be service connected. See 38 C.F.R. § 3.310(b) (2012); Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the non-service-connected disease or injury is said to have been aggravated by the service-connected disease or injury. See 38 C.F.R. § 3.310(b) (2012). In cases of aggravation of a Veteran's non-service-connected disability by a service-connected disability, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.322 (2012). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). 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. See 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). II. Analysis At the outset, the Board notes that service connection has been in effect for residuals of a cervical spine injury since February 1985, the date the Veteran initially underwent a surgical procedure to treat his cervical spine disability. Service connection has been in effect for DMII since April 2006. With respect to the current disability requirement for service connection, the Veteran was diagnosed with erectile dysfunction in an April 2008 VA genitourinary examination. He was previously noted to have erectile dysfunction during a VA examination for diabetes in December 2007. Accordingly, the Board finds that the current disability requirement for service connection for erectile dysfunction on a secondary basis has been met. See Davidson, supra; see also Wallin, supra. Turning then to the final required element to establish service connection for erectile dysfunction on a secondary basis, a nexus between the Veteran's current erectile dysfunction and his service-connected DMII and/or service-connected residuals of a cervical spine disability, the first noted instance of treatment for erectile dysfunction noted in the claims file is found in a February 1995 VA treatment report where he was noted to be having good results with use of papaverine/phentolamine (pap-phen). The record also reveals that the Veteran underwent circumcision in February 1995 to treat phimosis. At that time, he was noted to have an atrophic left testicle. He reportedly did not have a history of diabetes at that time. It appears that the Veteran was first diagnosed with DMII in 1997. Later, during an October 2000 VA consultation, he reported that he had failed to have an erection since he had started using Lisinopril. The assessment was, however, that an angiotensin-converting enzyme (ACE) inhibitor was unlikely to be the cause of his impotence. Although the Veteran underwent a cervical laminectomy at C3 through C6 with foraminotomy at C6-7 and C5-6, in February 1985, there is no contemporaneous evidence regarding the effect of this surgery on his erectile function. A July 1987 VA neurological examination report did note, however, that he had developed problems with ambulation, without bowel or bladder dysfunction. Other contemporaneous medical records also noted decreased function of the lower extremities During the December 2007 VA examination for diabetes, the VA examiner indicated that the cause of the Veteran's erectile dysfunction was diabetic neuropathy. The examiner further noted that the Veteran's erectile dysfunction was a complication of his diabetes, and that the onset of the erectile dysfunction was in relation to the onset of diabetes. During an April 2008 VA genitourinary examination, the examiner noted that the Veteran apparently received injections for erectile dysfunction in the early 1990s. The examiner again noted that the most likely etiology for his erectile dysfunction was diabetic neuropathy. The examiner provided the opinion, however, that the Veteran's erectile dysfunction was less likely as not caused by or a result of his DMII. The examiner reasoned that the Veteran was diagnosed with DMII in 1997, while he had been treated with pap-phen for erections as early as 1995. Thus, the examiner concluded that erectile dysfunction predated the Veteran's diabetes. The examiner did not, however, provide an opinion with respect to whether his erectile dysfunction was caused or aggravated by his service-connected residuals of a cervical spine injury. In his May 2008 notice of disagreement, the Veteran indicated that he began having problems keeping erections sometime after his surgery on his cervical spine. He also noted that he did not have a problem getting an erection until he was diagnosed with diabetes. He indicated that he even though he was not diagnosed with diabetes until 1997, he also had not been tested for diabetes prior to that time, and, as such, he may have had diabetes sometime prior to 1997. In November 2012, the Board made another attempt to ascertain the etiology of the Veteran's claimed erectile dysfunction by requesting a medical expert opinion from a healthcare professional in VA's Veterans Health Administration (VHA) as to whether it was at least as likely as not that the Veteran's erectile dysfunction was caused by diabetes mellitus, diabetic neuropathy, residuals of a cervical spine injury, kidney disease, or residuals of shell fragment wounds; and if not, whether it was at least as likely as not permanently aggravated by his service-connected diabetes and/or diabetic neuropathy. See 38 C.F.R. § 20.901(a) (2012) (the Board may obtain a medical opinion from an appropriate health care professional in the VHA of VA on medical questions involved in the consideration of an appeal when, in its judgment, such medical expertise is needed for equitable disposition of an appeal). In a December 2012 opinion, a VHA specialist reviewed the Veteran's history with respect to his cervical spine disability and his DMII. He noted the Veteran history of decreased function of the lower extremities. He also noted that although the February 1995 VA treatment report indicated that the Veteran did not have a history of diabetes, he did not find contemporaneous laboratory results in the record to support or refute the statement. The examiner further noted that phimosis/balanitis, with a resulting need for circumcision, is a common complication and presenting sign of diabetes. He similarly indicated that there were no laboratory findings of record to either support or refute a finding that the Veteran had diabetes prior to 1997. The VHA specialist noted that the Veteran had multiple risk factors for erectile dysfunction, including a cervical spine injury with neurological sequelae involving at least the left upper extremity and bilateral lower extremities, diabetes, hypertension and use of medication for hypertension, and renal insufficiency. He noted that it was most likely that all of these factors contributed, to a larger or lesser degree, to the Veteran's erectile dysfunction. The VHA specialist further indicated that diabetes was a particularly common contributor to erectile dysfunction, as it affects both the small blood vessels and the critical nerves of the penis. He additionally noted that cervical injuries and other spinal cord injuries were also a common source of erectile dysfunction, but that there was not adequate information in the record to comment further in the Veteran's case. After a review of the evidence of record, the VHA specialist concluded that there was at least a 50 percent probability (at least as likely as not) that the Veteran's erectile dysfunction was caused either by his DMII or his cervical injury. He additionally concluded that it was extremely likely that DMII also permanently aggravated the Veteran's erectile dysfunction. Based on the VHA specialist's well-informed, well-reasoned, and fully articulated opinion, the Board finds that a sufficient nexus exists between the Veteran's erectile dysfunction and his service-connected DMII and/or his service-connected residuals of a cervical spine injury, where the opinion indicated that there was at least a 50 probability that the Veteran's erectile dysfunction was caused either by his DMII or cervical spine injury. See Wallin, supra. Consequently, the Board finds that a discussion as to the issue of whether the Veteran's erectile dysfunction was permanently aggravated by his service-connected DMII is deemed unnecessary in this case. Accordingly, all doubt with respect to this claim is resolved in favor of the Veteran and his claim for service connection for erectile dysfunction as secondary to his service-connected DMII and residuals of a cervical spine injury is granted. 38 U.S.C.A. § 5107(b) (West 2002). ORDER Entitlement to service connection for erectile dysfunction as secondary to service-connected DMII and residuals of a cervical spine injury is granted. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs