Citation Nr: 1307931 Decision Date: 03/11/13 Archive Date: 03/20/13 DOCKET NO. 07-12 000 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for a urologic disability. 2. Entitlement to service connection for erectile dysfunction, to include hypogonadism. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD Scott Shoreman, Counsel INTRODUCTION The Veteran served on active duty from July 1966 to December 1969, including combat service in the Republic of Vietnam, and his decorations include the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. The Veteran and his spouse testified in August 2012 before the undersigned Veterans Law Judge (VLJ) at a hearing in Washington, DC. A transcript is of record. FINDINGS OF FACT 1. Resolving all reasonable doubt in the Veteran's favor, a urologic disability was caused by or aggravated by the service-connected prostate cancer. 2. Resolving all reasonable doubt in the Veteran's favor, erectile dysfunction, to include hypogonadism, was caused by or aggravated by the service-connected prostate cancer and posttraumatic stress disorder (PTSD). CONCLUSIONS OF LAW 1. The criteria for service connection for a urologic disability have been met. 38 U.S.C.A. §§ 1110, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 2. The criteria for service connection for erectile dysfunction, to include hypogonadism, have been met. 38 U.S.C.A. §§ 1110, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board grants service connection for a urologic disability and for erectile dysfunction, to include hypogonadism. As this represents a complete grant of the benefit sought on appeal, no discussion of VA's duty to notify and assist is necessary. 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). In addition to the elements of direct service connection and presumptive service connection, service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). 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."). Service connection is in effect for PTSD, prostate cancer, bilateral hearing loss, diabetes mellitus, type II, and bilateral tinnitus. The service treatment records show that in March 1961 the Veteran complained of swelling in the left groin area. He was referred to the urology clinic and was noted to have a bulge in the left inguinal canal. There were no other complaints or diagnoses related to a urologic disability or erectile dysfunction, to include hypogonadism, in the service treatment records. In July 2003 the Veteran had a VA genitourinary examination at which he gave a five to seven year history of erectile dysfunction associated with hypogonadism. He had been treated with hormonal replacement and Viagra. The Veteran was diagnosed with erectile dysfunction and hypogonadism. In December 2006 the Veteran had another VA genitourinary examination at which his chief complaint was progressive erectile dysfunction. Contributing factors were noted to be diabetes, hypertension, and exogenous obesity. At a February 2008 VA urology consultation the Veteran reported urinary frequency and urgency with some incontinence. Medication had helped resolve the symptoms, although there was still nocturia twice a night. The Veteran also reported poor libido and said that Levitra had been helpful. At March 2008 VA urology treatment the Veteran was noted to have a history of intermittent scrotal pain, sexual disinterest, and lower urinary tract symptoms that had resolved on terazosin. December 2008 private treatment notes show that the Veteran requested erectile dysfunction medication and said that in the past he used Viagra. He was prescribed Cialis. October 2009 VA treatment records indicate that the Veteran had urinary incontinence secondary to benign prostatic hypertrophy. It was also noted that the Veteran had erectile dysfunction. At an October 2009 VA general medicine examination it was noted that the Veteran had erectile dysfunction and urinary incontinence secondary to benign prostate hypertrophy. At a September 2011 diabetes and general medicine VA examination the Veteran was noted to have erectile dysfunction, and the examiner felt that the most likely cause was the blood pressure medication that the Veteran took. In December 2011 the Veteran had a VA examination for prostate cancer at which he reported urinary urgency, hesitancy/difficulty starting, weak or intermittent stream, a daytime voiding interval of two to three hours, and voiding three times per night. There was also post void dribbling without the need to wear absorbent materials. The Veteran also had erectile dysfunction, and the examiner felt that the most likely etiology was vascular disease. The Veteran testified at the August 2012 hearing that he started experiencing problems with erectile dysfunction and hypogonadism in 1968 when he returned from Vietnam. His wife testified that she had known him for 23 or 24 years and that he had had this problem the entire time. She further said that there was a psychiatric aspect, as the Veteran was affected by noises such as helicopters. The Veteran testified that he had had urinary problems for many years. The Veteran's private primary care provider wrote in a November 2012 statement that there was at least a 50/50 probability that the Veteran's erectile dysfunction was secondary to or the proximate result of PTSD. Furthermore, the Veteran's urinary disability was caused by or aggravated by prostate cancer. In February 2013 a private urologist wrote that erectile dysfunction is a recognized side effect of treatment for PTSD and was more likely than not secondary to the Veteran's PTSD. Furthermore, urinary incontinence may be related to prostate cancer. Considering all of the evidence of record, the Board finds that the Veteran's urologic disability cannot be reasonably disassociated from his service-connected prostate cancer. The primary care provider wrote in his November 2012 statement that the Veteran's urinary disability was caused by or aggravated by prostate cancer. Earlier records indicate that the Veteran had urinary incontinence secondary to benign prostatic hypertrophy. There are no opinions of record indicating that the urinary incontinence was not caused by or aggravated by the service-connected prostate cancer. Furthermore, the November 2012 opinion is of probative value because it was based on familiarity with the Veteran's medical history. See Stefl, 21 Vet. App. at 124. Therefore, the record shows that it is at least as likely as not that the urologic disability was caused by or aggravated by the service-connected prostate cancer. See 38 C.F.R. § 3.310. In regards to the Veteran's erectile dysfunction, to include hypogonadism, there are several medical opinions of record relating it to service-connected disabilities. The December 2006 VA genitourinary examiner felt that contributing factors to the erectile dysfunction included diabetes. Two opinions from private physicians discussed above indicate that the Veteran's erectile dysfunction was at least as likely as not secondary to PTSD. Therefore, the record shows that it is at least as likely as not that erectile dysfunction was caused by or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. In sum, the record shows that it is at least as likely as not that the urologic disability and erectile dysfunction, to include hypogonadism, are proximately related to service-connected disabilities. Thus, service connection for a urologic disability and erectile dysfunction, to include hypogonadism, is warranted. ORDER Service connection for a urologic disability is granted. Service connection for erectile dysfunction, to include hypogonadism, is granted. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs