Citation Nr: 1308301 Decision Date: 03/12/13 Archive Date: 03/20/13 DOCKET NO. 05-03 284A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi THE ISSUE Entitlement to service connection for chronic diarrhea, irritable bowel syndrome (IBS), and anal incontinence. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his daughter ATTORNEY FOR THE BOARD L. Durham, Counsel INTRODUCTION The Veteran served on active duty from March 2003 to November 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2004 rating decision issued by the VARO in Jackson, Mississippi, which denied service connection for incontinence and diverticulosis, claimed as intestinal problems. Although the Veteran initially appealed the denial of both claims, he withdrew his appeal as to diverticulosis in an August 2005 statement. See 38 C.F.R. § 20.204 (2012). As such, the sole issue before the Board is service connection for anal incontinence. In August 2005, the Veteran testified at a personal hearing before a Decision Review Officer (DRO) at the Jackson, Mississippi, RO. A transcript of this proceeding has been associated with the claims file. By a February 2010 determination, the Board denied the matter on appeal. The Veteran appealed the Board's decision with respect to this issue to the United States Court of Appeals for Veterans Claims (Court). In November 2011, the Court issued a memorandum decision setting aside the February 2010 Board decision and remanding the matter for further proceedings. The appeal has been returned to the Board for action consistent with the November 2011 memorandum decision. In response to the Veterans Health Administration (VHA) opinions as to the etiology of the Veteran's claimed condition, the Veteran and his representative have submitted additional arguments in support of his claim, including certain facts reported by the Veteran. To the extent that such arguments may be considered additional evidence in support of the claim, the Board notes that they are duplicative of the evidence that was considered by the agency of original jurisdiction (AOJ). As such, while a waiver was not submitted, the Board finds that it is not necessary to refer such information to the AOJ for consideration. See 38 C.F.R. §§ 20.800, 20.1304(c) (2012). FINDINGS OF FACT 1. Chronic diarrhea was noted on the Veteran's examination upon entry into active service and, therefore, preexisted his entrance into active service. This disability did not undergo an increase in severity during service, and chronic diarrhea is not otherwise shown to have been caused or aggravated by service. 2. The Veteran underwent an anal fissure surgery prior to his active duty service and, therefore, any residual disability related to this anal fissure or corrective surgery preexisted his entrance into active service. This residual disability did not undergo an increase in severity during service beyond the natural progression of the underlying disease and is not otherwise shown to have been caused or aggravated by service. 3. The most probative medical evidence of record does not reflect that the Veteran meets the criteria for a current diagnosis of IBS. CONCLUSION OF LAW Service connection is not warranted for chronic diarrhea, anal incontinence, or IBS. 38 U.S.C.A. §§ 1110, 1111, 1117, 1153, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306, 3.307, 3.317 (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 impose obligations on VA to provide claimants with notice and assistance. 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). Upon receipt of a substantially complete application for VA benefits, proper VCAA notice must be provided to a claimant prior to the initial unfavorable decision on the claim by the AOJ. Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). Here, the Veteran was advised in a February 2004 letter, sent prior to the initial unfavorable rating decision, of the evidence and information necessary to substantiate his service connection claim, as well as his and VA's respective responsibilities in obtaining such evidence and information. In addition, he was advised in a March 2006 letter of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/ Hartman. The Board notes that this letter was sent after the AOJ's initial unfavorable decision and, therefore, was not timely. See Pelegrini, 18 Vet. App. at 119-20. However, as the Veteran's claim was subsequently readjudicated in an August 2007 supplemental statement of the case (SSOC), such timing defect has been cured. 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 post-service VA and private treatment records have been obtained and considered. The Board notes that the Veteran identified treatment by Dr. E. in Memphis, Tennessee, for an anal sphincter repair in August 2003. The AOJ requested that the Veteran provide a valid address for Dr. E., but he was unable to do so. As such, the AOJ was unable to request treatment records from Dr. E. However, the Veteran provided pertinent records from Dr. E. in support of his claim. Moreover, the record includes medical evidence concerning the Veteran's medical condition before and after such procedure. The Board further notes that the Veteran indicated treatment by Dr. M. for the purpose of removing his gall bladder in July 2001. The AOJ requested records from Dr. M. but apparently received no response. However, such procedure and the Veteran's medical condition thereafter has been repeatedly documented in the medical evidence of record. For the foregoing reasons, the Board finds that the Veteran has not been prejudiced by the absence of any outstanding records from Dr. E. or Dr. M. Further, the Board notes that the Veteran submitted a copy of a letter from Social Security Administration (SSA) indicating that he is in receipt of SSA disability benefits. The United States Court of Appeals for the Federal Circuit (Federal Circuit) recently held that VA's duty to assist the Veteran extends only to obtaining relevant records, and there must be a reason to believe that records may give rise to pertinent information to conclude that they are relevant. See Golz v. Shinseki, 590 F.3d 1317 (2010). As the Veteran has not asserted that such SSA records would be pertinent to his claim or indicated that he would like VA to obtain such records, the Board finds that a remand to obtain such records is not necessary. Additionally, the Veteran was provided with VA examinations in connection with his service connection claim in November 2005, August 2006, and January 2007. The Board notes that the Veteran's representative argued in August 2009 that the case should be remanded for a VHA opinion as to the etiology of the Veteran's anal incontinence and, specifically, whether such disability was aggravated by active service. However, the Board forwarded the entire claims file for an opinion as to such issues by an appropriate VHA medical specialist, and a response was received in October 2009. Subsequent to a November 2011 Memorandum Decision, another VHA medical opinion was provided in September 2012 by a staff physician who specialized in gastroenterology. This physician subsequently offered an addendum opinion as well addressing this claim. A review of the opinion reveals no inadequacies. As such, the Board finds that the medical evidence of record is sufficient to decide the Veteran's claim. In the circumstances of this case, a remand would serve no useful purpose, as it would result in unnecessarily imposing 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). In this regard, 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 asserts that he is entitled to service connection for anal incontinence because such condition was incurred during active duty service in Kuwait from May to June 2003. Alternatively, he claims that such condition constitutes an aggravation of his preexisting chronic diarrhea as a result of a lack of proper medication and treatment while in Kuwait. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). A Veteran is considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. Only such conditions as are recorded in examination reports are considered as noted. A history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions but will be considered together with all other material evidence in determinations as to inception. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that such increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. 3.306(a). Clear and unmistakable (obvious and manifest) evidence is required to rebut the presumption of aggravation. 38 C.F.R. 3.306(b). Temporary or intermittent flare-ups during service are not sufficient to constitute aggravation unless the underlying condition, as distinguished from the symptoms, has worsened. The evidence must show a lasting worsening of the condition, meaning an increase in severity that existed at the time of separation from service and still exists currently. Hunt v. Derwinski, 1 Vet. App. 292, 296-97 (1991); Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002). When no preexisting condition is noted upon entry into service, the Veteran is presumed to have been sound upon entry. The burden then shifts to VA to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's condition was both preexisting and not aggravated by service. If VA fails to rebut the presumption of soundness, the Veteran's claim is treated as one for service connection. On the other hand, if a preexisting condition is noted upon entry into service, the Veteran can only bring a claim for aggravation of that condition, not for service connection for the condition itself. In such case, the Veteran has the burden to show aggravation through evidence of symptomatic manifestations of such condition during service. If the presumption of aggravation arises, the burden shifts to VA to establish a lack of aggravation. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); see also Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). In deciding a claim based on aggravation, after the presence of a preexisting condition has been established, the Board must determine (1) whether there has been any measured worsening of the condition during service, and (2) whether this constitutes an increase in disability. Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). 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. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). In this case, VA and private treatment records reflect that the Veteran had surgery to repair an anal fissure in 1996. Although there was a possible side effect of incontinence, the Veteran developed no diarrhea or anal incontinence at that time. The Veteran sought treatment from Dr. Williams in January 2003, at which point a colonoscopy revealed a few small-mouthed diverticula in the sigmoid colon but no other abnormalities. He was diagnosed with diverticulosis with symptoms of diarrhea and was treated with a high fiber diet and anti-diarrheal medication. The next month, the Veteran reported having had diarrhea since his gall bladder was removed a year and a half earlier. It appears that this surgery occurred anywhere from 1999 to 2001. The Veteran stated that his diarrhea had seemed to settle down for a while, but it had slowly gotten worse and worse. At that point, it was not uncommon for him to go 8-10 times daily, and there was a very strong sense of urgency associated with the diarrhea. The Veteran was diagnosed with chronic diarrhea, including recent spells with hematochezia (blood in the feces) of undetermined cause. The Veteran entered active duty service in March 2003 after having served in the Army National Guard for many years. His service treatment records include a pre-deployment examination in March 2003. The examiner noted in his report that the Veteran was taking medications for the removal of his gall bladder and diarrhea. The Veteran has reported that his chronic diarrhea was relatively stable with medication when he was deployed to Kuwait in May 2003. While in Kuwait, he had severe diarrhea, which he described as "running out" and into his pants. The Veteran believes this was due to him running out of his medications and/or stress and heat. He has stated that there was no progression of the condition; it "just started" while he was in Kuwait and has continued since that time. He has further stated that these problems were much worse than his "normal" bouts of diarrhea. The Veteran sought treatment while in Kuwait, but he was told that medications were not immediately available and they would have to work through the problem. In June 2003, before medications or further treatment could be obtained, the Veteran returned to the U.S. due to a family emergency. In July 2003, the Veteran again sought treatment from Dr. W., who noted that he had seen the Veteran several months earlier for ongoing and near debilitating issues with chronic diarrhea, which had started shortly after his gall bladder removal in 2000. He further noted that the Veteran's stools had reduced from 10 times daily to 2-3 times daily with medication, although the stools were still semi-solid. Dr. W. stated that the Veteran's most debilitating symptom was now a component of seepage versus incontinence. The Veteran reported that he had no warning symptoms and would feel small amounts of drainage between bowel movements. He would awaken several times at night due to soiled undergarments or pads, with the amount ranging from very little to roughly 1/4 cup. The Veteran denied abdominal pain, loss of appetite, and nausea. Physical examination of the rectal area revealed a reasonable sensation and ability to contract and relax the sphincter, and no fissures, fistulae, hemorrhoids, or internal abnormalities. The Veteran was diagnosed with diarrhea and fecal incontinence. Dr. W. commented that he was not sure if this was true incontinence, possibly from sensorineural damage from the prior sphincter surgery, or just seepage from a change to hemorrhoidal cushions, but that diarrhea was the main problem. Dr. W. referred the Veteran to a specialist, Dr. E., who performed an anal sphincteroplasty in August 2003. The Veteran was diagnosed with anal incontinence and a keyhole defect of the external sphincter. Dr. E. stated that the Veteran's previous sphincter surgery had scarred down and produced the keyhole defect, which resulted in anal incontinence. After this surgery, the Veteran was reassigned to Ft. Benning for further medical evaluation. An October 2003 service treatment record indicates that he was still having daily bowel leakage. He was diagnosed with anal incontinence status post anal sphincteroplasty and was cleared for deployment. The Veteran specifically denied pain in October 2003. Nevertheless, the Veteran did not return to Kuwait and was released from active duty in November 2003. The Veteran first sought treatment from VA in January 2004. At that time, he reported that his chronic diarrhea started in June 2003 while he was in Kuwait and became much worse when he returned to the U.S. on emergency leave. He reported no abdominal pain or change in appetite. He further reported that the treatment by Dr. W. and surgery by Dr. E. did not improve his condition but, rather, worsened it. The Veteran stated that he now had fecal incontinence that required him to wear diapers at all times, which greatly affected his work as a tree-trimmer and his personal life. He reported sleeping only 4-6 hours per night due to interruptions from diarrhea. Physical examination revealed mildly erythematous perirectal skin without open areas, a normal anal canal with good sphincter tone, liquid normal-colored stool, a normal prostate, and no fissure or hemorrhoids. The Veteran was diagnosed with diarrhea with fecal incontinence of unknown cause, identified as possible infection, diverticulosis, IBS, or smooth muscle/autonomic dysfunction. His medications were changed because the current regimen was not helping. Records from later that month indicate that the Veteran continued to have loose bowel movements/incontinence and was no better after the change in medication. Lab results for a stool culture were negative for occult blood, ova, and parasites. VA treatment records from February 2004 indicate that the Veteran's symptoms had improved when he went back on medication. However, he still had "leaks" of a small amount of loose stool 2-3 times per day and 3 times at night, which required him to wear a diaper at all times. He also had some improvement with a change in medication, although he still had 3-4 leaks per day. The Veteran reported that he could usually make it to the bathroom but not always, especially if he was in the field. He was diagnosed with chronic diarrhea with a component of incontinence, although the VA physician commented that it was unclear whether the incontinence was due to urgency. The VA physician noted a possibility of microscopic colitis if a lab work-up came back negative. He further noted that the Veteran reported having traveled in South America multiple times, with the last visit in 2001, but denied having any diarrhea during those times. The Veteran also continued seeing Dr. W. In June 2004, Dr. W. noted that the Veteran's diarrhea had seemed to settle down with medication in early 2003 but that he had developed a very different kind of diarrhea and significant incontinence issues after returning from Kuwait. He stated that the diarrhea was very watery and frequent, which was complicated by anal sphincter weakness from prior therapy on his anal fissure. Dr. W. stated that it was not clear what triggered the diarrhea while in Kuwait, as initial stool studies were negative. He noted that the Veteran's sphincter repair surgery had helped with some of the incontinence but not all of it. The Veteran had "basically" been controlling the problems with medication. He was again diagnosed with diarrhea, suspected as due to a choleretic source, and fecal incontinence. Dr. W. also began treating the Veteran for IBS because the problems were evolving into a chronic process. However, the Veteran did report some heartburn and abdominal pain at this time. In a July 2004 letter, Dr. W. stated that the Veteran had been stable and doing well on medication therapy for choleretic diarrhea after he was first seen in early 2003. He further stated that he saw the Veteran on an urgent basis when he returned from Kuwait in July 2003, and a work-up revealed a pre-existing sphincter defect from prior anal fissure therapy, for which he was referred for sphincter salvage repair. Dr. W. indicated that the Veteran's diarrhea was still present but under better control with anti-diarrheal medications. In October 2004, the Veteran was treated by Dr. W. as a follow up for diarrhea/IBS. He reported that he was doing very well since switching medications in July 2004 and had had no further incontinent episodes. The Veteran stated that he voided once daily and with proper form and control. He was diagnosed with IBS-diarrhea and incontinence post anal fissure surgery. However, he denied abdominal pain, loss of appetite, nausea, and vomiting. The Veteran was provided with a VA examination in November 2005, and the examiner discussed the Veteran's condition with a VA gastrointestinal specialist. The specialist indicated that it was not unusual to have chronic diarrhea and fecal incontinence with no history of anal sphincter surgery, especially among elderly patients. He stated that he did not think the Veteran's incontinence was due to him running out of medications while in Kuwait. The specialist opined that the Veteran's incontinence was likely due to preexisting chronic diarrhea post gall bladder removal and sphincter surgery. However, he strongly urged the VA examiner to get a surgical opinion. The Veteran was referred to Dr. F., a rectal surgeon, for another examination in August 2006. Dr. F. performed an anorectal ultrasound and diagnosed the Veteran with disruption of the internal sphincter on the left lateral and right lateral positions with anorectal incontinence. He noted that the Veteran had developed chronic diarrhea after his gall bladder surgery and, after running out of medicine in Kuwait, developed anal incontinence as to watery stool and flatus. He further noted that the Veteran was able to hold in hard, rocky stool. The Veteran reported that he was on a constipating regimen but still had at least one accident per day. Physical examination revealed an anterior keyhole deformity, and Dr. F. noted that such deformities are notoriously difficult to repair. He recommended that the Veteran be switched to a stronger constipation regimen. In January 2007, Dr. F. further opined that the Veteran's sphincter disruption could not be repaired surgically and a stronger constipating regimen was the only available treatment. A March 2007 VA treatment record indicates that the Veteran had fecal incontinence which began while he was in Kuwait. In addition to the Veteran's own lay statements, as summarized above, the evidence of record includes testimony from his daughter at an August 2005 hearing before a DRO at the AOJ. The Board notes that the Veteran's daughter is a nurse and, therefore, may have some specialized knowledge, experience, or training concerning his condition. However, she did not attempt to diagnose the Veteran but, rather, assisted him in reporting his symptoms. The Veteran has also submitted a statement from his wife, which was received in July 2004. She stated that the Veteran sought treatment in January 2003 because he had the urge to use the restroom 4-5 times a day but could not "do anything" once he got to the bathroom. She further stated that the medication prescribed by Dr. W. resolved the problem. The Veteran's wife reported that he had severe diarrhea when he returned from Kuwait, and it would run through his clothes during the day and when he was sleeping. She indicated that his treatment by Dr. W. and Dr. E. did not help. She further indicated that the Veteran's current medication helped some, but he was just living with the problem. In addition, the Veteran submitted a statement from his work supervisor, which was received in July 2004. The supervisor stated that he had worked with the Veteran on a daily basis for approximately 8 years and that the Veteran did not have a diarrhea problem before going to Kuwait. He stated that the Veteran had a bad problem with diarrhea when he returned from Kuwait, which affected his job performance. Upon review of the claims file, including the foregoing evidence, a VHA medical specialist opined in October 2009 that the Veteran currently has choleretic diarrhea after his gallbladder operation in 2001. He stated that there is a component of IBS to the diarrhea, as stated by Dr. W. in June and October 2004, and that there is also rectal incontinence after sphincterotomy for fissure repair in 1996. Based on this evidence, the specialist opined that the Veteran had chronic diarrhea when he entered active duty in March 2003. He stated that it was possible that the IBS component of the diarrhea got worse during active duty, but that is questionable. The specialist noted that Dr. W. had made several statements indicating that the Veteran's diarrhea was under control when he was taking the treatment prescribed. Therefore, the specialist opined that the Veteran's preexisting condition of chronic diarrhea did not permanently increase in severity beyond its natural progression as a result of service. He further opined that the medical opinions of record appeared to be very reasonable considering the evidence of record. Due to the November 2011 memorandum decision, another VHA medical opinion was provided by a gastroenterology staff physician in September 2012. This physician noted that he or she was making the following assumptions: (1) the issue before the Board is entitlement to service connection, s/p anal sphincteroplasty (to include the diagnosis that is eventually determined to be the cause of this condition. For ease of reference, this condition is referred to as anal incontinence throughout this enquiry; (2) anal incontinence is the failure of control of the anal sphincters, with involuntary passages of feces and flatus, which may be psychogenic or organic in nature; (3) sphincteroplasty is reparative or plastic surgery of a sphincter; and (4) IBS is a common intestinal condition characterized by abdominal pain and cramps, changes in bowel movements (diarrhea, constipation, or both), gassiness, bloating, nausea, and other symptoms. With regard to question (1), whether, when the Veteran was stationed in Kuwait and his diarrhea returned, is it possible to conclude that the pre-existing service connection was aggravated by the Veteran's military service, the examiner answered 'no', there was no recognized pre-existing 'service condition' at the time of his deployment to Kuwait. If the question refers to the pre-existing diarrhea/incontinence symptoms, the condition showed a temporary 'flare-up' while in Kuwait most likely due to an interruption in use of prescribed medications (cholestyramine, etc.) which were keeping the Veteran's symptoms under control. With regard to question (2), whether, when the Veteran's diarrhea became 'non-treatable in Kuwait, did the disability become permanently more severe, or was the disability merely aggravated to such an extent that the symptoms produced could be classified as a 'flare-up' and non-permanent in nature, the examiner answered 'no', the disability did not become permanently more severe. The disability was aggravated to such an extent that the symptoms could be classified as a non-permanent flare. With regard to question (3), the physician determined that the records indicate that, when the Veteran returned from Kuwait, the symptoms related to his diarrhea were more severe along with a change in the quality of symptoms. With regard to question (4), the examiner indicated that the medical evidence did not establish that the diarrhea condition became more severe during service such that the symptoms and manifestations produced exceeded the natural progression of the disease. Post-cholecystectomy diarrhea would typically not get progressively worse. Anal incontinence due to post-surgical state or otherwise would gradually deteriorate, but such natural progression of the disease would occur gradually over several years. With regard to question (5), the physician determined that the keyhole defect was present prior to deployment. The etiology of this defect is most likely a residual of the remote anal fissure surgery. The Veteran might have had it for some time, but per record, it was definitively diagnosed by rectal ultrasound in July 2003. There is no record which establishes that the sphincter defect was the manifestation of the anal incontinence. Rather the defect was the cause of chronic anal incontinence. There is no evidence of record that established that 'but for' the Veteran's in service in Kuwait, he would not have developed this defect. Question (6) noted that, in October 2009, a VA examiner hypothesized that "it is possible that the IBS component of the diarrhea got worse while he was (on) active duty, but this is questionable". The physician noted that he concurred with the October 2009 VA examiner's hypothesis. IBS is a clinical diagnosis and the diagnosis is made by confirming a symptom complex in combination with exclusion of other illnesses that could produce similar symptoms. In order to diagnose IBS in a given individual, internationally accepted Rome III Criteria are used. Diagnostic criteria: recurrent abdominal pain or discomfort at least 3 days/month in the last 3 months associated with 2 or more of the following: (1) improvement with defecation, (2) onset associated with a change in frequency of stool, (3) and onset associated with a change in form (appearance) of stool. For IBS to be diagnosed, the symptoms must have started at least 6 months prior and must have occurred at least 3 days per month of the previous 3 months. Further testing is not usually needed, though the healthcare provider may do a blood test screen for other problems. Additional diagnostic tests may be needed and include a stool test, lower GI series, and flexible sigmoidoscopy or colonoscopy. All this evaluation was performed in this case. Prior to his Persian Gulf War deployment, the Veteran had at least 2 established conditions that could explain his diarrhea: (1) post-anal surgery incontinence, (2) post-cholecystectomy diarrhea. Hence, his pre-deployment diarrhea/incontinence symptoms could not be attributed to IBS alone. As the symptoms of diarrhea existed for 6 months or more prior to deployment, there possibly was at the most a "component" of IBS to his symptoms merely based on the duration and frequency of symptoms. What is lacking is the symptom of 'recurrent abdominal pain or discomfort' which is an important diagnostic criterion for IBS. With regard to question (7), the physician indicated that the medical evidence of record did not suggest, insinuate, or positively show that the Veteran was suffering from IBS prior to his deployment to Kuwait. The physician noted that the records suggest per the treating physician Dr. W., "the diarrhea could be traced back to a year and a half ago when he had his gallbladder removed". In view of the duration of the diarrhea alone, a possibility of IBS is suggested at this point. However, as outline in the answer to question 6 above, the absence of "recurrent abdominal pain or discomfort" makes the diagnosis of IBS questionable. With regard to question (8), the physician noted that the medical evidence of record did not suggest, insinuate, or positively show that the Veteran's IBS was the result of or caused by or due to his service. The medical evidence of record fails to convincingly show that the Veteran suffered for IBS as defined by the Rome Criteria and that it was the result of, or caused by or due to his service. In October 2012, it was requested that this physician provide an addendum opinion with regard to several of the responses in the September 2012 opinion. Specifically with respect to question 4, the physician noted that, when the Veteran was deployed, he had the following conditions: anal incontinence due to anal fissure surgery likely of several years' duration, post-cholecystectomy diarrhea controlled on Questran, and his pre-deployment records do not indicate that he had abdominal pain or discomfort which is a cardinal symptoms for IBS. Thus, he did not have a diagnosis of IBS prior to deployment. While on active duty, he did not have access to medicines (Questran) prescribed for his diarrhea. These medicines were controlling his symptoms prior to deployment. This lack of medication caused his diarrhea symptoms to significantly worsen. Symptoms of post-cholecystectomy diarrhea are expected to be worse in an individual without an intact anal sphincter than one with an intact anal sphincter. The information in the Veteran's medical records is indicative of a post-surgical anal sphincter defect combined with post-cholecystectomy diarrhea previously well-controlled on medications, and aggravated while on active duty due to more than 3 weeks interruption of medications. Hence, the worsening of the Veteran's symptoms was a natural progression of the underlying disease. Apart from the fact that his medication got temporarily interrupted while in service, his service had no effect on the symptoms. Despite, laboratory testing and colonoscopy, no additional cause was found for aggravation of diarrhea symptoms. With regard to question (5), the physician noted that his or her original reply stated that the keyhole defect in the anal sphincter was most likely caused by the anal fissure surgery performed in October 1994. It was not known if this defect occurred immediately after that surgery or some time later. The Veteran did not have ano-rectal ultrasound or anal manometry performed prior to his deployment. The operative notes of the surgeon who performed the anal sphincteroplasty in August 2003 mentioned that "there was a keyhole defect in the left lateral portion of the external sphincter, at the site of the previous fissurectomy." Thus, the defect was likely present for several years. When the Veteran had gallbladder surgery in 2002 and developed post-cholecystectomy, combined with the post-cholecystectomy diarrhea, this defect gave the Veteran his symptoms. The physician stated that there was no discrepancy in the previous statements. The defect was proven after he returned to CONUS in 2003, but was most likely present long before. The exact day the defect arose cannot be determined. With respect to question (6), the physician noted that Rome III criteria are internationally accepted criteria for diagnosing functional bowel disorders. They are well accepted in the U.S. gastroenterology community. Hence, they were used in giving an opinion on this case. As mentioned before, 'abdominal pain or discomfort' is an essential component of IBS and diagnosis of IBS becomes very questionable in the absence of such symptom. Nowhere in the Veteran's available record, abdominal pain or discomfort are mentioned, neither prior to or post-deployment. Prior reviewers do not seem to have taken this aspect into consideration. Somewhere along the Veteran's evaluations, a presumptive additional diagnosis of "IBS" was loosely applied to the Veteran's case without applying strict clinical diagnostic criteria because of the persistent diarrhea component. The diagnosis of "IBS" has persisted throughout the appeals process. By internationally accepted criteria of IBS, the Veteran does not have "IBS". He has post-fissurectomy anal sphincter defect (with dialed attempt at repair), leading to incontinence combined with post-cholecystectomy diarrhea. As noted above, a memorandum decision was issued by the Court in November 2011 with regard to the Board's February 2010 denial of the claim on appeal. In this memorandum decision, the Court stated that it perceived that there are 3 issues for review: (1) service connection for aggravation of chronic diarrhea; (2) service connection for anal incontinence insofar as this condition is distinguishable from the chronic diarrhea; and (3) service connection for IBS. As such, the Board will address these issues in this order. With regard to the Veteran's chronic diarrhea, the Board evidence of record clearly reflects that he experienced diarrhea prior to his active duty service. Specifically, the Veteran sought treatment from Dr. W. in January 2003, at which point he was diagnosed with diverticulosis with symptoms of diarrhea and was treated with a high fiber diet and anti-diarrheal medication. The Veteran entered active duty service in March 2003 after having served in the Army National Guard for many years. His service treatment records include a pre-deployment examination in March 2003, on which it was noted that the Veteran was taking medications for the removal of his gall bladder and diarrhea. As such, the Board finds that the presumption of soundness does not apply with regard to the Veteran's chronic diarrhea. Thus, the Board must consider whether there was an increase in disability during such service so as to warrant the presumption of aggravation. 38 U.S.C.A. § 1153 (West 2002). If so, clear and unmistakable evidence that such increase was not beyond the natural progress of the disease is required to rebut the presumption of aggravation. With regard to whether there was an increase in the Veteran's diarrhea during his service so as to warrant the presumption of aggravation, as note above, temporary or intermittent flare-ups during service are not sufficient to constitute aggravation unless the underlying condition, as distinguished from the symptoms, has worsened. The evidence must show a lasting worsening of the condition, meaning an increase in severity that existed at the time of separation from service and still exists currently. Hunt v. Derwinski, 1 Vet. App. 292, 296-97 (1991); Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002). Upon review of the all relevant evidence of record, the Board finds that the Veteran suffered a temporary flare-up relating to his diarrhea symptoms in service. Specifically, the evidence reflects that the Veteran's chronic diarrhea was manifested by increased symptoms during active service including increased frequency and amount of diarrhea, as well as a watery consistency. However, shortly after service, the Veteran was placed back on his medication, and this increase in symptoms subsided. Specifically, VA treatment records from February 2004 indicate that the Veteran's symptoms had improved when he went back on medication. In June 2004, Dr. W. noted that the Veteran's diarrhea had seemed to settle down with medication in early 2003 but that he had developed a very different kind of diarrhea and significant incontinence issues after returning from Kuwait. In a July 2004 letter, Dr. W. stated that the Veteran had been stable and doing well on medication therapy for choleretic diarrhea after he was first seen in early 2003. In October 2004, the Veteran was treated by Dr. Williams as a follow up for diarrhea/IBS. He reported that he was doing very well since switching medications in July 2004 and had had no further incontinent episodes. The Veteran stated that he voided once daily and with proper form and control. He was diagnosed with IBS-diarrhea and incontinence post anal fissure surgery. Therefore, while these records do not reflect that the Veteran's diarrhea symptoms resolved completely, the medical evidence of record does reflect that the flare in symptoms that the Veteran experienced during active duty appeared to have subsided, and the symptoms returned to their pre-service severity by 2004. Additionally, the September 2012 VHA opinion indicated that, with regard to the question of whether, when the Veteran was stationed in Kuwait and his diarrhea returned, is it possible to conclude that the pre-existing service connection was aggravated by the Veteran's military service, the examiner answered 'no', there was no recognized pre-existing 'service condition' at the time of his deployment to Kuwait. If the question refers to the pre-existing diarrhea/incontinence symptoms, the condition showed a temporary 'flare-up' while in Kuwait most likely due to an interruption in use of prescribed medications (cholestyramine, etc.) which were keeping the Veteran's symptoms under control. This VHA opinion went on to note that the Veteran's diarrhea did not become permanently more severe while in Kuwait. The disability was aggravated to such an extent that the symptoms could be classified as a non-permanent flare. Further, the physician determined that the medical evidence does not establish that the diarrhea condition became more severe during service such that the symptoms and manifestations produced exceeded the natural progression of the disease. Post-cholecystectomy diarrhea would typically not get progressively worse. Anal incontinence due to post-surgical state or otherwise would gradually deteriorate, but such natural progression of the disease would occur gradually over several years. Therefore, upon review of all relevant evidence of record, the Board finds that the record contains clear and unmistakable evidence that any increase in the Veteran's diarrhea during service was a temporary flare-up and did not result in permanent aggravation beyond the natural progress of the disease. As noted, temporary or intermittent flare-ups during service are not sufficient to constitute aggravation unless the underlying condition, as distinguished from the symptoms, has worsened. The evidence must show a lasting worsening of the condition, meaning an increase in severity that existed at the time of separation from service and still exists currently. Hunt v. Derwinski, 1 Vet. App. 292, 296-97 (1991); Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002). In this case, a lasting worsening of symptoms is not shown by the evidence of record, as discussed above. Instead, the probative medical evidence reflects that the Veteran had a flare-up of diarrhea symptoms in service due to not having access to medications but that this flare-up was temporary and did not result in a lasting worsening of the condition. Therefore, the Board finds that the presumption of aggravation does not attach. As the claims file contains clear and unmistakable evidence that there was no aggravation of a pre-existing disability in service beyond the natural progress of the disease, service connection cannot be granted for chronic diarrhea. With regard to the issue of service connection for anal incontinence insofar as this condition is distinguishable from the chronic diarrhea, the Board finds that the presumption of soundness does apply in this case, as the Veteran was not specifically noted upon his entrance into active duty as having undergone an anal fissure surgery or having anal incontinence. However, the Board also finds that the presumption of soundness is rebutted in this case, as there is clear and unmistakable evidence reflecting that the Veteran underwent an anal fissure surgery prior to active duty service. Significantly, a service treatment record signed by the Veteran in October 1996 noted his report of having had surgery with his rectum. Moreover, the other evidence of record also reflects that the Veteran underwent sphincter surgery at some point prior to service to repair an anal fissure. Dr. E., who performed an anal sphincteroplasty in August 2003, diagnosed the Veteran with anal incontinence and a keyhole defect of the external sphincter. Dr. E. stated that the Veteran's previous sphincter surgery had scarred down and produced the keyhole defect, which resulted in anal incontinence. Additionally, the November 2005 VA gastrointestinal specialist indicated that anal incontinence is related to the Veteran's prior anal fissure surgery. The September 2012 VHA opinion noted that anal incontinence due to post-surgical state or otherwise would gradually deteriorate, but such natural progression of the disease would occur gradually over several years. Further, the physician determined that the keyhole defect was present prior to deployment. The etiology of this defect is most likely a residual of the remote anal fissure surgery. The Veteran might have had it for some time, but per record, it was definitively diagnosed by rectal ultrasound in July 2003. There is no record which establishes that the sphincter defect was the manifestation of the anal incontinence. Rather the defect was the cause of chronic anal incontinence. Additionally, the Board notes that the Veteran has never denied that he underwent an anal fissure surgery prior to his active duty service. Therefore, as it is clear that the Veteran had an anal fissure prior to his active duty service that required surgery and ultimately resulted in a keyhole defect, the presumption of soundness is rebutted. In finding that the presumption of soundness has been rebutted, the Board notes that anal incontinence has been determined by the medical evidence of record to be a residual symptom related to a surgery to repair an anal fissure. Therefore, the fact that anal incontinence did not manifest prior to service does mean that the Veteran was in sound condition in this regard. It simply means that the Veteran was not having residual symptoms pertaining to his anal fissure and related surgery upon entrance into service. As the Board finds that the presumption of soundness has been rebutted, the Board must consider whether there was an increase in disability during such service so as to warrant the presumption of aggravation. 38 U.S.C.A. § 1153 (West 2002). If so, clear and unmistakable evidence that such increase was not beyond the natural progress of the disease is required to rebut the presumption of aggravation. In this regard, the Board notes that the Veteran reported having severe diarrhea beginning while he was in Kuwait. However, his reported symptoms also seem to suggest that fecal incontinence began, or in other words any residual disability related to his previous sphincter surgery was aggravated, at this time as well. Specifically, Dr. W. diagnosed the Veteran with fecal incontinence in July 2003. However, Dr. W. commented that he was not sure if this was true incontinence, possibly from sensorineural damage from the prior sphincter surgery, or just seepage from a change to hemorrhoidal cushions, but that diarrhea was the main problem. In August 2003, Dr. E. performed an anal sphincteroplasty and stated that the Veteran's previous sphincter surgery had scarred down and produced the keyhole defect, which resulted in anal incontinence. An October 2003 service treatment record indicates that he was still having daily bowel leakage. In a January 2004 VA treatment record, the Veteran asserted that the surgery by Dr. E. worsened his condition and he now had fecal incontinence that required him to wear diapers at all times. The Veteran was diagnosed with diarrhea with fecal incontinence of unknown cause. In a February 2004 VA treatment record, the Veteran reported that his symptoms had improved some. He was diagnosed with chronic diarrhea with a component of incontinence, although the VA physician commented that it was unclear whether the incontinence was due to urgency. In October 2004, the Veteran reported that he was doing very well since switching medications in July 2004 and had had no further incontinent episodes. A March 2007 VA treatment record indicates that the Veteran had fecal incontinence which began while he was in Kuwait. Therefore, as the Veteran did not complain of any anal incontinence symptoms prior to his active duty, and it appears that the Veteran did have a problem with anal incontinence after his active duty service, the Board finds that the presumption of aggravation is warranted. However, the Board also finds that the claims file contains clear and unmistakable evidence that such increase was not beyond the natural progress of the disease, and, as such, the presumption of aggravation is rebutted. In this regard, the Board notes that the November 2005 VA specialist indicated that he did not think the Veteran's incontinence was due to him running out of medications while in Kuwait but that the Veteran's incontinence was likely due to preexisting chronic diarrhea post gall bladder removal and sphincter surgery. However, the August 2006 VA examiner indicated that the Veteran had developed chronic diarrhea after his gall bladder surgery and, after running out of medicine in Kuwait, developed anal incontinence as to watery stool and flatus. The September 2012 VHA opinion addressed this issue in more detail. Specifically, the September 2012 VHA medical opinion indicated that, with regard to question (1), whether, when the Veteran was stationed in Kuwait and his diarrhea returned, is it possible to conclude that the pre-existing service connection was aggravated by the Veteran's military service, the examiner answered 'no', there was no recognized pre-existing 'service condition' at the time of his deployment to Kuwait. If the question refers to the pre-existing diarrhea/incontinence symptoms, the condition showed a temporary 'flare-up' while in Kuwait most likely due to an interruption in use of prescribed medications (cholestyramine, etc.) which were keeping the Veteran's symptoms under control. The physician further noted that anal incontinence due to post-surgical state or otherwise would gradually deteriorate, but such natural progression of the disease would occur gradually over several years. In the addendum opinion, the specialist clarified his or her opinion further. The specialist noted that the Veteran had anal incontinence due to anal fissure surgery likely of several years' duration. Further, the physician noted that, while on active duty, the Veteran did not have access to medicines (Questran) prescribed for his diarrhea medications. These medicines were controlling his symptoms prior to deployment. This lack of medication caused his diarrhea symptoms to significantly worsen. Symptoms of post-cholecystectomy diarrhea are expected to be worse in an individual without an intact anal sphincter than one with an intact anal sphincter. The information in the Veteran's medical records is indicative of a post-surgical anal sphincter defect combined with post-cholecystectomy diarrhea previously well-controlled on medications, and aggravated while on active duty due to more than 3 weeks interruption of medications. Hence, the worsening of the Veteran's symptoms was a natural progression of the underlying disease. Apart from the fact that his medication got temporarily interrupted while in service, his service had no effect on the symptoms. The physician further clarified that the keyhole defect in the anal sphincter was proven after the Veteran returned to CONUS in 2003, but was most likely present long before. When the Veteran had gallbladder surgery in 2002 and developed post-cholecystectomy diarrhea, this defect, combined with the post-cholecystectomy diarrhea gave the Veteran his symptoms. Upon review of all relevant medical evidence of record, the Board finds the addendum to the September 2012 VHA is the most probative medical opinion of record. This specialist reviewed the claims file thoroughly and offered a detailed rationale for his or her opinions. Therefore, as this specialist ultimately concluded that the worsening of the Veteran's symptoms was a natural progression of the underlying disease, the Board finds that the presumption of aggravation is rebutted and service connection must be denied. With regard to service connection for IBS, the Board notes that the Veteran was diagnosed in a January 2004 VA treatment record with diarrhea with fecal incontinence of unknown cause, identified as possible infection, diverticulosis, IBS, or smooth muscle/autonomic dysfunction. In June 2004, Dr. W. began treating the Veteran for IBS because the problems were evolving into a chronic process. The Veteran did report some heartburn and abdominal pain at this time. In the October 2009 VHA opinion, the physician stated that there is a component of IBS to the diarrhea, as stated by Dr. W. in June and October 2004. Based on this evidence, the specialist stated that it is possible that the IBS component of the diarrhea got worse during active duty, but that is questionable. On the other hand, however, the September 2012 VHA opinion indicated that what is lacking is the symptom of 'recurrent abdominal pain or discomfort' which is an important diagnostic criterion for IBS. The physician further noted that the medical evidence of record fails to convincingly show that the Veteran suffered for IBS as defined by the Rome Criteria and that it was the result of, or caused by or due to his service. It was further clarified that nowhere in the Veteran's available record, abdominal pain or discomfort are mentioned, neither prior to or post-deployment. Prior reviewers do not seem to have taken this aspect into consideration. Somewhere along the Veteran's evaluations, a presumptive additional diagnosis of "IBS" was loosely applied to the Veteran's case without applying strict clinical diagnostic criteria because of the persistent diarrhea component. The diagnosis of "IBS" has persisted throughout the appeals process. By internationally accepted criteria of IBS, the Veteran does not have "IBS." He has post-fissurectomy anal sphincter defect (with dialed attempt at repair), leading to incontinence combined with post-cholecystectomy diarrhea. The Board acknowledges that Dr. W. noted the Veteran as having IBS, a diagnosis that the October 2009 VHA opinion assumed to be accurate. However, in this case, the Board finds the September 2012 VHA opinion and addendum opinion to be more probative on this matter. Specifically, the September 2012 VHA opinion and addendum opinion were based on detailed review of the claims file and thoroughly discussed the criteria for a diagnosis of IBS and why the Veteran does not meet such a criteria. Dr. W. offered no such analysis and instead simply indicated that he began treating the Veteran for IBS because the problems were evolving into a chronic process. Dr. W. provided no discussion as to how the Veteran could be diagnosed with IBS without abdominal pain or what symptoms specific to IBS the Veteran demonstrated. As such, the Board finds the September 2012 VHA opinion and addendum opinion to be the most probative medical evidence of record as to the matter of whether the Veteran has a current diagnosis of IBS. Therefore, as these opinions determine that the Veteran does not meet the criteria for IBS, the Board finds that service connection cannot be granted for IBS. The Board notes that the claims file does contain an isolated complaint of abdominal pain in June 2004. However, the Veteran also denied abdominal pain in several other instances, to specifically include in October 2003, June 2004, and October 2004. As a single complaint for abdominal pain would not meet the criteria for 'recurrent abdominal pain or discomfort', the Board find this isolated complaint has no impact on the September 2012 VHA and addendum opinions. Further, as the Veteran served on active duty in Kuwait, the Board has considered the special provisions pertaining to Persian Gulf War Veterans. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. However, as discussed above, the Board has concluded that the probative medical evidence of record does not reflect that the Veteran meets the criteria for IBS. Moreover, the Board has concluded that the Veteran's chronic diarrhea existed prior to service and the Veteran's anal incontinence is related to a pre-service surgery. As such, service connection is not warranted under 38 C.F.R. § 3.317. The Board notes that the Veteran believes that his current condition is the result of a lack of proper treatment during service. Certainly, the Veteran can attest to factual matters of which he had first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the Veteran as a lay person has not been shown to be competent to offer an opinion on complex medical questions, such as whether chronic diarrhea, IBS, or anal incontinence is related to his active duty service. See Jandreau v. Nicholson, 492 F.3d, 1372, 1377 (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). While the Veteran is competent to report what comes to him through his senses, he does not have medical expertise. See Layno v. Brown, 6 Vet. App. 465, 469-470 (1994). As such, the Board ultimately places more probative value on the detailed September 2012 VHA opinion and addendum opinion provided by the staff physician who specializes in gastroenterology. With regard to the statements from the Veteran's daughter, who, as a nurse, is not considered a lay person, the Board notes that she did not attempt to diagnose the Veteran or provide etiologies for his conditions but, rather, assisted him in reporting his symptoms. Likewise, the Board has considered statements from this Veteran's wife and a co-worker. However, these statements speak to the reporting of symptoms, as opposed to providing etiologies. Moreover, as lay persons, the Board would again place more probative value on the September 2012 VHA opinion and addendum opinion for the reasons discussed above. In summary, the Board concludes that the clinical evidence of record does not reflect that the Veteran meets the criteria for a diagnosis of IBS. Additionally, the Board concludes that the Veteran's chronic diarrhea and status post anal fissure surgery ultimately resulting in anal incontinence clearly and unmistakably existed prior to service and clearly and unmistakably were not aggravated beyond the natural progress of the diseases during service. For these reasons, and as no current diagnosis related to IBS, chronic diarrhea, or incontinence, status post anal sphincteroplasty, has otherwise been shown by credible or competent evidence to be related to his military service, the claim for service connection must be denied. See 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for chronic diarrhea, IBS, and anal incontinence is denied. ____________________________________________ A. C. MACKENZIE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs