Citation Nr: 1307102 Decision Date: 03/01/13 Archive Date: 03/11/13 DOCKET NO. 08-25 790 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to compensation for a bladder disability, to include under 38 U.S.C.A. § 1151 due to surgery performed by VA in August 1992, or as secondary to service-connected erectile dysfunction. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD C. Fields, Associate Counsel INTRODUCTION The Veteran served on active duty from July 30, 1956, to December 11, 1956. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The Veteran testified as to the issue on appeal at a formal hearing before a Decision Review Officer (DRO) at the RO in July 2008, as well as in an informal conference in January 2009. The Veteran also testified concerning this issue before the Board at a hearing at the RO in August 2010. A transcript of each hearing and the informal conference report are of record. The Board remanded this issue for consideration of newly received and submitted evidence by the agency of original jurisdiction (AOJ), in accordance with the Veteran's wishes, in December 2011. This was completed, and sufficient development has been conducted for a fair adjudication, as discussed below. The Veteran submitted evidence and statements in support of his claim after the last supplemental statement of the case was issued in July 2012. The Veteran's representative waived review of any such evidence by the agency of original jurisdiction (AOJ) in a July 2012 statement. Therefore, the Board may properly consider such evidence at this time. See 38 C.F.R. §§ 20.800, 20.1304(c) (2012). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran does not have additional bladder disability as a result of VA care, treatment, or services; moreover, the evidence does not demonstrate that any possible additional disability was due to any fault on the part of VA in providing the care or treatment, to include failure to obtain informed consent prior to the surgery, or that any additional disability was due to an unforeseeable event. 2. The Veteran's bladder disability was not proximately caused or aggravated by his service-connected erectile dysfunction; and is not directly related to service. CONCLUSION OF LAW The criteria for entitlement to compensation for a bladder disability, to include under 38 U.S.C.A. § 1151 due to surgery performed by VA in August 1992, or as secondary to service-connected erectile dysfunction, have not been met. 38 U.S.C.A. §§ 1101, 1112, 1131, 1151, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310, 3.361 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations require VA to provide claimants with notice and assistance in substantiating a claim. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not in the record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 186 (2002). These notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Proper VCAA notice must be provided to a claimant prior to the initial unfavorable decision on the claim. Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). Here, the Veteran was advised in April 2007, prior to the initial rating decision in October 2007, of the evidence and information necessary to substantiate his claim for a bladder disability as secondary to his service-connected erectile dysfunction, as well as the responsibilities of the Veteran and VA in obtaining evidence relevant to the claim. Thereafter, in December 2007, the Veteran was further advised of the evidence and information necessary to establish entitlement to compensation pursuant to 38 U.S.C.A. § 1151, as well as a disability rating and an effective date, in accordance with Dingess/Hartman. The timing defect as to this letter was cured by the subsequent readjudication of the claim, including in a July 2012 supplemental statement of the case. See Prickett v. Nicholson, 20 Vet. App. 370, 376-77 (2006); Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). With regard to the duty to assist, the Veteran's service treatment records and VA treatment records dated from 1987 through January 2009 have been obtained. This includes records dated within the months before and immediately after the August 1992 surgery at issue, as well as the signed consent form for the surgery. The Board notes that all pertinent documents in the Veteran's Virtual VA file (a highly secured electronic storage system) are also in his paper claims file. The Veteran has also submitted certain records and letters from private providers. He has been advised on several occasions that he must complete an authorization form for VA to obtain any further non-VA records, or that he may provide such records himself, and he has not done so. VA's duty to assist in developing the pertinent facts and evidence in connection with a claim is not a one-way street, and the Veteran has a responsibility to cooperate in such development. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Moreover, there is no indication that any outstanding private records would be likely to help substantiate his claim, to include establishing additional disability as a result of the VA surgery. Rather, the private records do not pertain to the period of time around the surgery, as the identified treatment was received several years after the VA surgery at issue. As such, the Veteran is not prejudiced by the absence of any possibly outstanding records. The Veteran's bladder condition before and after the VA care, treatment, or services at issue is established by the currently available evidence. There is also evidence concerning the Veteran's erectile dysfunction. VA obtained several medical opinions as to the cause of the Veteran's current condition through both VA examinations and a VHA medical opinion. The Veteran has also submitted private medical opinions, which will be considered together with the other evidence. The Board notes that the Veteran has requested a "new trial" and that he wants VA to subpoena one of his VA providers to testify. See, e.g., July 2012 statement. Although VA is authorized to subpoena a witness to testify in certain circumstances, this is not such a case. See 38 C.F.R. § 20.711 (2012). In particular, the minimal requirements for a motion to subpoena have not been met (including the name and address of the witness, and why his attendance could not be obtained without a subpoena). Further, the Veteran's request was not received at least 30 days prior to the hearing. See id. As such, a motion has not been received. Additionally, VA proceedings are nonadversarial in nature and there is no "trial." Instead, the Veteran has been afforded both a formal DRO hearing and a Board hearing before the undersigned. He is not entitled to another hearing, and he has not described good cause for a new hearing. Further, there is no indication that another hearing would provide any further support for his claim. Rather, the Veteran fully described his contentions through questioning from both his representative and the individual conducting the respective hearings (including the undersigned). In particular, the Veteran testified as to his bladder symptoms before and after the surgery and his assertions as to fault on the part of VA, including as to what he states that the VA provider whom he wants to subpoena told him. The hearings focused on the elements necessary to substantiate the claim, and there is no indication or argument that any notification deficiencies resulted in prejudice or otherwise affected the essential fairness of the adjudication of the Veteran's claim. In particular, neither the Veteran nor her representative has argued that VA failed to comply with 38 C.F.R. 3.103(c)(2), or identified any prejudice as a result of the RO or Board hearing. Rather, the Veteran has had ample opportunity to participate in the adjudication of his claim. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). VA has also substantially complied with the duties set forth in 38 C.F.R. 3.103(c)(2), consistent with Bryant v. Shinseki, 23 Vet. App. 488 (2010). As discussed above, the prior remand directives have been completed, and no further evidence is necessary for a fair adjudication. A further remand would serve no useful purpose, as it would unnecessarily impose additional burdens on VA with no benefit to the Veteran. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). VA has satisfied its duties to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceedings. As such, the Veteran will not be prejudiced by a decision on the merits of his claim. II. Analysis The Veteran filed an initial claim in August 1999 for compensation pursuant to 38 U.S.C.A. § 1151 based on an August 1992 surgery, referring to erectile dysfunction and voiding or urinary symptoms. VA initially addressed only the claim for erectile dysfunction, which was eventually granted in a November 2006 rating decision. Thereafter, the Veteran filed a claim for service connection for a bladder disability as secondary to erectile dysfunction based on the August 1992 surgery. VA adjudicated the claim for compensation for a bladder disability pursuant to 38 U.S.C.A. § 1151 (claimed as secondary to erectile dysfunction) in an October 2007 rating decision. This appeal followed. Service connection may be granted on a secondary basis for a disability that is proximately caused or aggravated by a service-connected disability. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). When a veteran suffers a qualifying additional disability or death as the result of hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy program furnished by VA, compensation will be awarded in the same manner as if such additional disability or death were service-connected. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361. For claims filed on or after October 1, 1997, the additional disability or death must have been directly caused by carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of VA. 38 C.F.R. § 3.361(c), (d). This standard will be met if VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or if VA furnished treatment, care, or examination without the informed consent of the veteran. 38 C.F.R. § 3.361(d)(1). Alternatively, compensation will be awarded if additional disability or death was directly caused by an event not reasonably foreseeable. 38 C.F.R. § 3.361(d)(2). When there is an approximate balance of positive and negative evidence regarding any material issue, all reasonable doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Here, the Veteran contends that he has additional bladder disability as a result of a VA surgery performed on August 31, 1992, and that such additional disability was due to fault on the part of VA. The Veteran also believes that his bladder condition is related to his erectile dysfunction. He was previously granted compensation for erectile dysfunction under 38 U.S.C.A. § 1151 based on a finding that erectile dysfunction developed as an unforeseen consequence of the August 1992 surgery. The Veteran and his representative have advanced several arguments, most of which focus on whether there was fault on the part of VA. The question of whether VA was at fault, however, to include due to a failure to obtain informed consent before surgery, is relevant only if a determination is made that the Veteran has additional disability that is the result of VA care, treatment or services. To determine whether the Veteran has additional disability as a result of the VA treatment at issue, the Board must compare his condition immediately before the surgery to his condition after the surgery and related care. 38 C.F.R. § 3.361(b). The evidence must show that VA's care, treatment, or examination actually caused additional disability. Merely showing that the Veteran received VA care, treatment, or examination and that he has additional disability does not establish causation. 38 C.F.R. § 3.361(c)(1). Such care, treatment, or examination cannot cause the continuance or natural progress of a disease or injury unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused its continuance or natural progress. 38 C.F.R. § 3.361(c)(2). Further, additional disability caused by the Veteran's failure to follow properly given medical instruction is not caused by VA care, treatment, or examination. 38 C.F.R. § 3.361(c)(3). The Veteran asserts that he developed additional bladder symptoms after the August 1992 VA surgery, and that these are a direct result of the surgery. The Veteran also states that these symptoms progressed over time, resulting in the need for corrective surgery and the current level of disability. The Board will focus on the Veteran's bladder or urinary symptoms shortly before and after the surgery. The Board first notes that the claims file includes several copies of a letter dated in May 1993 that he states he submitted to his VA provider, one of the surgeons who performed the surgery at issue and chief of urology at the time, approximately 6 to 9 months after the surgery. This letter is not included in the treatment records that were obtained. Rather, it was only submitted by the Veteran during the course of this appeal, and he also submitted a pencil-written copy that he states is the original letter. Under these circumstances, it is unclear if the letter was actually sent to VA providers in May 1993. Nevertheless, it will be considered with the other evidence. At times, the Veteran denies having had any urinary problems at all prior to the surgery, and he denies having told VA providers that he had trouble urinating all his life, or since his early childhood. See, e.g., November 2001 letter from Dr. Taylor, October 2005 VA examination report, October 2009 letter from Veteran, August 2010 Board hearing transcript. At other times, the Veteran states that he only had a split stream and some trouble urinating, without inability to urinate, before the surgery. See, e.g., letter by Veteran directed to VA provider dated in May 1993, March 2007 letter from Veteran to VA, July 2008 DRO hearing transcript. The Veteran has specified several times that, prior to the August 1992 surgery, he never had a burning sensation when urinating, slow flow of urine, urinary incontinence or leakage, or needed to push or press on his bladder to get urine to flow. He states that all of these problems began only after the surgery. See, e.g., January 2003 and March 2007 letters, July 2008 DRO hearing transcript. During an October 2000 VA examination, the Veteran reported symptoms before the August 1992 surgery of urinary frequency during the day, nocturia, narrow stream, and split stream, but no pain or post void dribbling. He referred to the May 1993 letter as showing complaints of increased frequency of urination, having to press on his bladder to empty, more frequent nocturia, and increased difficulty voiding after intercourse after the surgery. Similarly, in an April 2003 VA treatment record, the Veteran reported having a narrowed stream, nocturia, and daytime urinary frequency, but no need to strain prior to the surgery. He stated that he began to have dysuria (or painful urination), difficulty urinating, urinary incontinence, and post-void dribbling after the surgery. In a March 2007 letter to VA, the Veteran again reported some level of nocturia prior to the August 1992 surgery, with increased frequency of need to urinate at night after the surgery. In contrast, during a July 2008 DRO hearing, the Veteran testified that he never had to urinate at night before the surgery at issue. In the letter directed to a VA provider dated May 1993, the Veteran also wrote that he was able to urinate almost normally for approximately 6 months after the surgery, but he had been having problems urinating for the past 3 months (or in early 1993). In contrast, during the August 2010 Board hearing, he testified that he could not urinate immediately or about 2 weeks after the August 1992 operation. The Board notes that the Veteran's descriptions of his urinary or bladder symptoms before and after the August 1992 VA surgery, as summarized above, are internally inconsistent. They are also inconsistent with the VA treatment records for several years before and after the August 1992 VA surgery. Rather, as discussed below, such records show that the Veteran had longstanding urinary or bladder problems, and that he had similar symptoms before and after the surgery at issue. In particular, the Veteran's claims that he never had a burning sensation or had to strain or press on his bladder prior to the surgery are directly contradicted by the medical evidence. The Veteran also reported having problems since childhood on several occasions. For example, in October 1990, the Veteran complained of nocturia up to 6-7 times per night, intermittent burning sensation or pain with urination, double or split strain, urinary stammer, difficulty initiating stream, needing to press on the bladder, and mild dribbling. An October 1990 consult request notes complaints of split stream and frequency. In a March 1991 urology consult, the Veteran reported that "all his life" he has had "marked frequency and nocturia," and he was now noting splitting of the stream and occasional dribbling. A May 1991 record reflects that he continued to have nocturia, frequency, urgency, split stream, and dribbling. The Veteran was scheduled for an internal urethrotomy (the same surgery that was performed in August 1992) in November 1991, but he had to reschedule. Similarly, in March 1992, the Veteran reported frequent urination at night every hour, a desire to void, urgency, fullness of the abdomen, straining, the need to crede (or press on the bladder), hesitancy, frequency, double urination, and post void dribbling. The Veteran again reported urinary difficulty that started at 2 years old and frequent urination as a child. In June 1992, he continued to complain of frequency, frequent nocturia, and burning with urination. An August 19, 1992, record again notes that the Veteran complained of frequency and smaller stream than all his friends ever since starting school. An August 20, 1992, record notes that a urethral pressure profile (UPP) showed signs of severe hesitancy, fairly adequate voided volume, increased flow time, decreased time to peak that was noted to be possibly due to straining, and very decreased maximum and average flow peak. The August 31, 1992, full operative report records that the indications for the surgery were a history of split stream and slowing force of stream, with evidence of urethral stricture. A discharge summary notes a history of complaints of frequency, hesitancy, and nocturia 3-4 times a night. Nursing documentation dated September 5, 1992, notes that the Veteran had been discharged after surgery on September 3, 1992. He complained of severe bladder pain with some blood oozing from the urethra around the Foley catheter, but he had good urine output. On September 8, 1992, the Veteran reported being able to urinate as he had prior to the surgery, with frequency, slight dysuria, decreased force of stream, and some hematuria. A September 15, 1992, record notes that the Veteran's urination was only 5 percent better, he had good control, and was stable. Several months later, in June 1993, the Veteran reported frequent sensations of not emptying the bladder completely and needing to urinate again less than 2 hours afterwards, stopping and starting several times while urinating, weak urinary stream, needing to push or strain to begin urination, difficulty postponing urination, and needing to urinate at night every hour. In May 1994, the Veteran was noted to have nocturia 7-8 times, frequency, etc., with no improvement in symptoms after the August 1992 VA surgery. The Veteran continued to be treated for bladder or urinary symptoms over the years by both VA and private providers, with increasing symptoms, multiple cystoscopies and other diagnostic tests, self-catheterization for several years, and another internal optical urethrotomy in 2009. The Veteran and his representative are not competent, as lay witnesses, to testify as to the cause of his current bladder disability. This includes include whether it constitutes additional disability as a result of any VA care or treatment, whether there was any fault on the part of VA in providing such treatment, or whether the bladder disability was caused or aggravated by erectile dysfunction. Rather, such questions require specialized knowledge, training, or experience due to the complex nature of the genitourinary system. See Barr v. Nicholson, 21 Vet. App. 303, 308 (2007); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In contrast, the Veteran is competent to report having additional or worsened urinary or bladder symptoms after the August 1992 VA surgery, as these would be within his realm of personal observation. See id. Nevertheless, as summarized above, the Veteran's statements in this regard are internally inconsistent, as well as inconsistent with his statements for treatment purposes contemporaneous to the surgery. The Board recognizes that many years have passed since the surgery, including at the time the Veteran first filed a claim for VA compensation pertaining to the surgery in 1999. As a result, he may have trouble remembering the nature and severity of his symptoms before and after the surgery. In contrast, the claims file contains multiple medical records dated for several years prior to the surgery, including during the weeks before and after the surgery, and for several years after the surgery. The Board finds these records to be much more probative in determining the nature and severity of the Veteran's symptoms at those times, as his statements were made in order to obtain accurate treatment. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made for medical treatment purposes may be afforded greater probative value because there is a strong motive to tell the truth in order to receive proper care). They were also made many years prior to his claim for VA benefits. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (testimony may not be ignored simply because the witness is an interested party, but interest in the outcome may affect the credibility of testimony). For the foregoing reasons, the Board finds the Veteran's statements as to the timing and severity of his urinary or bladder symptoms for the purposes of this claim to be not credible. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (witness credibility may be impeached by a showing of interest, bias, or inconsistent statements). Additionally, the Board requested an opinion from a specialist with the Veterans Heath Administration (VHA) as to whether there was additional disability after the August 1992 VA surgery and the cause of any such disability. In a June 2011 report, a VHA urologist opined that the Veteran's bladder disability is not related to the August 1992 VA surgery. The specialist reasoned that the Veteran had significant symptoms and prior documentation in 1991 of a long bulbar urethral stricture. The specialist stated that most of the bladder symptoms are likely a result of urethral stricture disease that had been present for several years prior to the 1992 procedure. He explained that significant urethral obstruction will result in irreversible bladder change, symptoms of which would most likely be urgency, frequency, urge incontinence, and dysuria. The specialist further stated that benign prostatic hypertrophy (BPH) would also complicate management of these symptoms. The VHA specialist's opinion is consistent with the Board's credibility determination herein concerning the timing of the Veteran's symptoms. The Board acknowledges that the Veteran believes that he did not have a urethral stricture prior to the August 1992 VA surgery. He relies on statements by providers Dr. C (dated in January 2001 and January 2009) and Dr. T (dated in November 2001 and May 2002), which were based primarily on review of an August 19, 1992 x-ray/retro urethrogram (RUG) prior to the surgery. The Veteran also states that a VA provider reviewed the same records in January 2001 and stated that there was no urethral stricture, but would not put this in writing. See, e.g., January 2003, October 2009, and July 2012 letters from Veteran; August 2010 hearing transcript. None of these providers, however, appears to have reviewed the other pertinent VA treatment records. In particular, in addition to the August 19, 1992, RUG/x-ray report, another RUG/x-ray in April 1991 showed urethral stricture, as well as a cystoscopy in March 1991, which could not be fully completed due to the stricture. See also May and October 1991 records summarizing the results. Further, an August 20, 1992, urethral pressure profile showed symptoms of lower urinary obstruction, and that together with the cystoscopy and RUG were found to be all in favor of a long and narrow urethral stricture. Urethral stricture was also found and incised (cut) during the August 31, 1992, surgery, as shown by full operative report. Indeed, a VA examiner stated in October 2006 that the Veteran most likely had a bulbar urethral stricture as well as BPH at the time of the surgery. She explained that all of the Veteran's studies prior to the August 31, 1992, procedure show that there was evidence of obstruction. As noted above, the VHA specialist indicated in June 2011 that BPH could also complicate the Veteran's urinary symptoms. Additionally, in a February 2002 addendum report, a different VA examiner noted the January 2001 opinion of Dr. C that the August 19, 1992, RUG/x-ray report did not appear to show a urethral stricture, and if a cystoscopy did not also show a stricture then urethrotomy (or the August 31, 1992, surgery) was not indicated. The VA examiner stated that, in fact, a stricture was identified by cystoscopy before the operation, noting that a cystoscopy the prior year had been aborted due to urethral stricture. This is consistent with the March 1991 cystoscopy report and the subsequent VA records in April, May, and October 1991 noting a stricture. The Board finds that the VA medical evidence and the VA examiners' opinions, as discussed above, outweigh the opinions of the other providers as to whether the Veteran had a urethral stricture prior to the surgery at issue. This is because the opinions relied on by the Veteran, namely those of Dr. C and Dr. T, did not consider all pertinent evidence and, therefore, those opinions have very little probative weight. In contrast, the VA examiners considered all pertinent evidence. The weight of the evidence shows that the Veteran did have a urethral stricture. The Board notes that the evidence also reflects a diagnosis of urethral strictures after the August 1992 VA surgery. See, e.g., September 1993, June 1997, and September 1999 VA records; March 1998 and July 2005 private records. In a November 2001 letter, however, Dr. T stated that cystoscopic and visual examination of the urethra and bladder showed evidence of a previous procedure in bulbar area of the urethra that had healed in a "wide open" position, and that this was presumed to be the area where an incision was made during the prior surgery. Similarly, a VA examiner stated in an October 2006 report that the August 1992 surgery appeared to be successful in opening the Veteran's urethral stricture. Nevertheless, to the extent that the post-surgery strictures may be related to the one that was operated on in August 1992, there is evidence indicating that they may have been caused by Veteran's failure to follow medical advice. Specifically, the Veteran had a Foley catheter removed early, against medical advice, after the August 31, 1992, surgery. This is clear from the VA records and, indeed, the Veteran admits that this occurred. The medical records also document that VA providers repeatedly explained the possible consequences of removing the catheter due to inadequate healing time, including recurrence of the stricture, bleeding, infection, or lack of control. See, e.g., September 1-8, 1992, VA treatment records; January 2003, March 2007 letters from Veteran; July 2008 and August 2010 hearing transcripts. Two VA examiners noted in February 2002 and March 2005 that the Veteran's postoperative course was complicated by his demanding early removal of the catheter despite being advised repeatedly of the possible complications. As noted above, additional disability caused by the Veteran's failure to follow properly given medical instruction is not considered to be caused by VA care, treatment, or examination. 38 C.F.R. § 3.361(c)(3). As discussed above, the VHA specialist and VA examiners (as well as VA and private providers) have noted that the Veteran's urinary or bladder symptoms could also be due to BPH. The evidence demonstrates that the Veteran was diagnosed with BPH, or enlarged prostate or prostatitis, both before and after the VA surgery at issue, and there was repeated discussion of medications and/or surgery to treat the prostate condition. See, e.g., pre-surgery VA records dated in October 1990, October 1991, June 1992; August 19, 1992, RUG x-ray; post-surgery VA records dated in August 1994, March 1999, November 2004, November 2008; private records dated in March 1998, October 1998, November 2001. To the extent that the Veteran claims that his current condition is due to worsened prostate problems after the surgery, the Board acknowledges that he has also asserted at times that he underwent a TURP (transurethral resection of the prostate), not an optical urethrotomy, on August 31, 1992. This belief is based primarily on a notation by Dr. C in an August 2001 patient referral and clinical data form that he had a TURP at that time. The Veteran states that this was an erroneous procedure, that he told his providers that he did not want prostate surgery, and that the TURP damaged his prostate or created scar tissue to result in his current bladder problems. See, e.g., January 2003 letter from Veteran; July 2008 DRO hearing transcript. As noted by two separate VA examiners in a February 2002 addendum report and a March 2005 examination report, however, this appears to be an erroneous notation by Dr. C. Rather, all available medical records from that time, including nursing operating room records and the dictated operative record, contradict this allegation. The Veteran had an optical urethrotomy, otherwise known as a DVIU (direct visual internal urethrotomy). As also noted by the second VA examiner in an October 2006 examination and addendum report, multiple urologists conducted cystoscopies after the August 1992 surgery, including by VA in September 2004, which showed a slightly dilated bulbar urethra that was consistent with the previous procedure. There was median lobe enlargement and no evidence of a prior TURP. A private urologist also agreed that the Veteran had no evidence of a previous TURP. See, e.g., December 1998 private record (noting that the Veteran was status post DVIU, and recommending a possible TURP at that time); November 2001 letters from Dr. T (stating that there was no evidence of the prostate having been resected in the past, and recommending a TURP at that time to remove obstructing prostate tissue). The Veteran has also asserted that, regardless of whether he had a TURP or a urethrotomy, he has scar tissue as a result of the surgery that is causing his problems. See, e.g., July 2008 and August 2010 hearing transcripts. This is contradicted, however, by the medical evidence of record. A May 2003 VA cystoscopy report notes that the Veteran had a small band of tissue (or scar) in the prostatic urethra. The provider goes on to state that he initially thought that this band of tissue was the cause of the Veteran's problems, but on further examination, there was no compromise to the urethral lumen, so this was not felt to be problematic. Further, in an October 2006 report, a VA examiner noted that the Veteran believes that there was damage during the August 1992 surgery, but stated that subsequent cystoscopies by multiple institutions did not support this belief. Further, both VA and private providers have repeatedly recommended that the Veteran take medications or have a TURP to treat his BPH and likely reduce his bladder symptoms. Although the Veteran initially took some medications such as proscar, which were noted to improve his symptoms, he later refused to take anything other than herbal supplements, and he has repeatedly refused a TURP. See, e.g., May 1994, August 1994, and November 2004 VA records; March 1998 and December 1998 private records; November 2001 letters from Dr. T. For all of the above reasons, the evidence does not establish that the Veteran has additional bladder disability as a result of the August 31, 1992, VA surgery. Therefore, compensation may not be granted pursuant to 38 U.S.C.A. § 1151. In an abundance of caution, to the extent that the evidence may be interpreted to show additional bladder disability as a result of the VA surgery, to include increased frequency of urination, difficulty voiding, or trabeculation, the Board has also considered whether the evidence shows any instance of fault on the part of VA. In this regard, the Veteran believes that the August 1992 surgery of urethrotomy should not have been performed for several reasons. First, he asserts that he did not have a urethral stricture and, therefore, no surgery was necessary. He has also indicated at times that he was erroneously given a TURP although he did not want prostate surgery. As discussed above, the more probative evidence shows that the Veteran did, in fact, have a urethral stricture prior to the surgery. Further, the more probative evidence shows that an optical urethrotomy, not a TURP, was performed. The Veteran also asserts that there was fault during the surgery itself, including damaging his prostate or urethra. The Veteran has submitted several articles indicating that VA providers have made mistakes in other cases concerning treatment or surgery. None of these articles has any direct bearing on the Veteran's case, and the fact that a mistake or instance of fault may have occurred in another case does not establish fault in this case. As discussed above, the Veteran's allegations of fault in his case are not supported by the medical evidence. Further, a VA examiner indicated in March 2005 and October 2006 that the Veteran's urethral stricture was well and appropriately treated with urethrotomy and subsequent care. Therefore, no fault is shown on this basis. Next, the Veteran contends that fault is shown because he did not give informed consent to a urethrotomy. He states that he thought he was undergoing a non-surgical procedure in which a balloon would be used to dilate his urethra, and that he told his providers that he did not want them to cut him. The Veteran also states that he was not aware that he would need a Foley catheter in place for 8 or more days after the surgery, and he thought it would only be needed for 1-2 days. The informed consent form for the surgery, signed by the Veteran and a witness on August 28, 1992, is in the claims file. The consent form reflects that the Veteran was to undergo an optic urethrotomy and possible bladder biopsy. The nature and purpose of the operation was listed as to "cut urethral stricture, biopsy bladder if tumor seen." The list of possible complications includes bleeding, infection, and recurrence of the stricture. The Veteran was noted to have the opportunity to ask questions and indicated comprehension of the discussion. Similarly, an August 28, 1992, nursing note records that the Veteran had signed the surgical consent form and indicated knowledge of the surgical procedure. The nurse expressly noted that the Veteran understood that there may be "Foley, etc. as appropriate," and that he was being admitted for "an operation in my urethra" in the Veteran's words. The Veteran's statements that he did not agree to being cut during the surgery are directly contradicted by the signed consent form. Although the consent form does not specifically mention the length of time a Foley catheter would be required after the surgery, this level of detail is not required in writing. The pre-surgery nursing note indicates that this was discussed with the Veteran, and a post-surgery medical record dated September 3, 1992, also indicates that the length of catheterization that was recommended is generally standard procedure. Further, VA examiners indicated in March 2005 and October 2006 that the Veteran's urethral stricture was appropriately treated with urethrotomy and appropriate placement of Foley catheter after the procedure. Postoperative recovery was also noted to be complicated by the Veteran's demand to have the catheter removed prior to the recommended date. The Veteran is competent to describe his understanding of the August 1992 procedure and the nature of his consent; however, the Board finds his statements for the purposes of this claim to be not credible. As with the timing of his symptoms, these statements are inconsistent with the medical evidence, as well as the signed consent form. Those records are more probative because they are contemporaneous to the actions at issue and were made many years prior to the Veteran's claim for compensation. Therefore, the Board finds that the Veteran was fully informed of the nature and the possible risks of the surgery, and there was no fault in this respect. Similarly, there is no indication that the Veteran's bladder symptoms after the surgery, to include any that may be due to recurrence of stricture, are the result of any unforeseen circumstance. Rather, recurrence of stricture was specifically contemplated by the informed consent form. Additionally, the treatment records clearly document that he was advised during recovery from the August 1992 surgery that the urethral stricture may return if he had the catheter removed earlier than advised, which he ultimately did do against medical advice. With regard to secondary service connection, the VHA specialist indicated in June 2011 that there was no connection between the Veteran's bladder disability and erectile dysfunction. There is also no other medical evidence to suggest that the bladder disability was proximately caused or permanently worsened beyond its natural progression (aggravated) by the erectile dysfunction. As noted above, the Veteran is not competent to offer an opinion in this regard. As such, secondary service connection is not warranted. See 38 C.F.R. § 3.310. The Board has also considered whether service connection is warranted on a direct basis due being incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1113(b), 1131; 38 C.F.R. § 3.303. As discussed above, the more probative evidence shows that the Veteran has had bladder problems for many years, including in childhood. There is no argument or indication that his bladder disability had its onset or was aggravated during his active service in 1956. In summary, the weight of the evidence does not demonstrate that the Veteran has additional bladder disability as a result of the August 31, 1992, VA surgery. Moreover, the weight of the evidence does not demonstrate any fault on the part of VA, to include failure to obtained informed consent prior to the surgery, or that any possible additional disability was due to an unforeseeable event. Rather, the preponderance of the evidence is against compensation for a bladder disability pursuant to 38 U.S.C.A. § 1151. The preponderance of the evidence is also against service connection for the Veteran's current bladder disability as secondary to the service-connected erectile dysfunction, based on either causation or aggravation, or as directly related to military service. Therefore, the benefit of the doubt doctrine does not apply and the Veteran's claim must be denied. 38 U.S.C.A. § 5107. ORDER Entitlement to compensation for a bladder disability, to include under 38 U.S.C.A. § 1151 due to surgery performed by VA in August 1992, or as secondary to service-connected erectile dysfunction, is denied. ____________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs