Citation Nr: 1311271	
Decision Date: 04/05/13    Archive Date: 04/19/13

DOCKET NO.  08-00 968	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Oakland, California


THE ISSUE

Entitlement to service connection for impotence, including as secondary to 
service-connected degenerative disc disease of the lumbar spine (low back disability).


REPRESENTATION

Appellant represented by:	The American Legion


WITNESS AT HEARING ON APPEAL

The Appellant-Veteran


ATTORNEY FOR THE BOARD

C. Bruce, Counsel


INTRODUCTION

The Veteran served on active duty from January to May 1991.

This appeal to the Board of Veterans' Appeals (Board) is from a December 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).

In October 2012, the Veteran testified at a hearing at the RO before the undersigned Veterans Law Judge of the Board (Travel Board hearing).


FINDING OF FACT

Although the Veteran has a diagnosis of impotence, the most persuasive evidence indicates it is a complication of his hypogonadism, not caused or even exacerbated by his service-connected low back disability, including the treatment (epidural injections) he has received for this service-connected disability.


CONCLUSION OF LAW

His impotence is not shown to be proximately due to, the result of, or chronically aggravated by a service-connected disability - namely, his low back disability.  38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012).



REASONS AND BASES FOR FINDING AND CONCLUSION

The Duties to Notify and Assist

Before addressing the underlying merits of a claim, the Board generally is required to ensure that VA's duties to notify and assist the claimant with the claim have been satisfied under the Veterans Claims Assistance Act (VCAA).  38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a).

Upon receipt of a complete or substantially complete application for benefits, VA must inform the claimant of any information and medical or lay evidence not of record:  (1) that is necessary to substantiate the claim; (2) that VA will obtain and assist the claimant in obtaining; and (3) that the claimant is expected to provide.  See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002).

These notice requirements apply to all elements of a service-connection claim, including the "downstream" disability rating and effective date elements.  See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007).

A letter satisfying these notice requirements of 38 C.F.R. § 3.159(b)(1) was sent to the Veteran in September 2006, so in the preferred sequence, that is, before initially adjudicating his claim in the December 2006 decision at issue.  See Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II).  The letter informed him of the evidence required to substantiate this claim and of his and VA's respective responsibilities in obtaining this supporting evidence.  The letter also complied with Dingess by as well discussing the "downstream" disability rating and effective date elements of this claim, in the event service connection is eventually granted.  So he has received all required notice concerning this claim.


And as for the duty to assist, the RO obtained his service treatment records (STRs), as well as private and VA evaluation and treatment records - including the reports of his VA compensation examinations.  During the course of the appeal, the RO has requested that he identify any outstanding and relevant records, VA or private, and there is no suggestion there are additional records needing to be obtained, which are obtainable.

There is a duty to provide a VA examination for a medical nexus opinion concerning etiology when the record lacks evidence needed to decide the Veteran's claim but there is evidence of:  (1) a current disability (including persistent or recurrent symptoms of disability), (2) an in- service event, injury, or disease, and (3) some indication that the claimed disability may be associated with the established event, injury, or disease.  38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006).

When determining whether a VA examination and opinion are required under 38 U.S.C. § 5103A(d)(2), the law requires competent evidence of disability or persistent or recurrent symptoms of disability, but does not require competent evidence of a nexus, only that the evidence suggest an association between the disability and service or a service-connected disability.  See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010).

Here, a VA examination specifically addressing this claim at issue was provided in August 2012, including for an etiological (i.e., medical nexus) opinion regarding whether the Veteran's service-connected low back disability either caused or is aggravating his impotence so as to warrant the granting of service connection on this alleged secondary basis.  When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate.  Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  The Board finds that the VA examination and opinion obtained in this case are more than adequate, as they are collectively predicated on a full reading of the medical records in the Veteran's claims file for the pertinent history of these and other disabilities.  The examiner considered all of the pertinent evidence of record and the statements of the Veteran and provided a complete rationale for the opinion offered, relying on and citing to the records reviewed that are most pertinent.  Accordingly, the Board finds that VA's duty to assist in obtaining a VA examination or opinion has been met.  38 C.F.R. § 3.159(c)(4) (2012).

The Veteran has received all essential notice, has had a meaningful opportunity to participate effectively in the development of this claim, and is not prejudiced by any technical notice deficiency along the way.  See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004).  So, in summary, it is difficult to discern what additional guidance VA could have provided him regarding what further evidence he should submit to substantiate this claim.  See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances when a remand would not serve any useful or meaningful purpose or result in any significant benefit to the Veteran).

Rather recently, in October 2012, as support for this claim, the Veteran testified at a hearing at the RO before the undersigned Veterans Law Judge (VLJ) of the Board, which, as already alluded to, is often and more commonly referred to as a Travel Board hearing.  In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U. S. Court of Appeals for Veterans Claims (Court/CAVC) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ who chairs a hearing fulfill two duties to comply with this VA regulation.  These duties consist of:  (1) fully explaining the issue or issues and (2) suggesting the submission of evidence that may have been overlooked.  Here, during the hearing, the presiding VLJ explained the basis of the prior determination denying this claim and discussed the element of the claim (supporting medical nexus evidence) that was lacking to substantiate entitlement to this claimed benefit.  In addition, the VLJ sought to identify any pertinent evidence not then currently of record that might have been overlooked or was outstanding that might tend to substantiate the claim.  Indeed, to this end, the Veteran was asked whether he had the required supporting medical nexus evidence establishing the necessary correlation (causation or aggravation) between his service-connected low back disability and impotence, to which he responded "no".

When questioned further concerning this regarding exactly what his doctors had said when asked, he responded they had not really said anything definitive.  He posited there was nonetheless this correlation between these disabilities on the premise that he had not had any morning erections since receiving the last of 3 epidural injections into his spine in 2002 or thereabouts, so he believed the clearly sudden onset of his impotence immediately following that last epidural injection, which he said was a double one, was reason enough to conclude that injection and the ones prior are the reason he has been impotent ever since.  He added that he had a very healthy sex life prior to receiving those injections, but that ever since his testosterone level has been low, which has been treated with a medication supplement to increase it so he can still have sex.  But even with that, he said, he does not actually have an ejaculation and does not feel anything that the pleasure of sexual intercourse is supposed to bring.

In later testimony during his hearing, he said he was intending to see a medical doctor the same morning as that hearing, and that he would ask the doctor whether there is indeed a relationship or correlation between the impotence and service-connected low back disability, including as a result of the epidural injections mentioned.  The Veteran closed by saying he would then submit this medical opinion himself in support of his claim, if provided.  It apparently was not provided, however, since, for the reasons and bases that will be discussed, the preponderance of the evidence is instead against his claim.

He therefore clearly has been made aware of the type of evidence lacking as concerning his claim.  And, in truth, he has evidenced his actual knowledge of the need for this supporting medical evidence.  Actual knowledge is established by statements or actions by him or his representative demonstrating an awareness of what is necessary to substantiate his claim.  Moreover, neither he nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or otherwise identified any prejudice in the conducting of that hearing.  To the contrary, the hearing focused on the element necessary to substantiate the claim.  As such, the Board finds that, consistent with Bryant, the presiding VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board resultantly may proceed to adjudicating this claim based on the existing record.

In deciding this claim, the Board has reviewed all of the evidence in the Veteran's claims files, both his physical claims file and electronic ("Virtual VA") claims file.  Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by him or obtained on his behalf be discussed in exhaustive detail.  Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim.  See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000).

Merits of the Claim

Service connection is granted if the evidence shows a current disability resulted from an injury or a disease that was incurred or aggravated during active military service in the line of duty.  38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a).  Service connection also may be granted for a disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service.  38 C.F.R. § 3.303(d).

So, to reiterate, establishing entitlement to direct service connection generally requires:  (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a nexus or link between the injury or disease in service and the current disability.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002).  See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999).


If chronicity (permanency) of disease or injury in service is not shown, or legitimately questionable, then a showing of continuity of symptomatology following service is required to support the claim.  38 C.F.R. § 3.303(b).  Under § 3.303(b), an alternative method of establishing the second and third Shedden elements is through a demonstration of continuity of symptomatology.  Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999).  Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the 
post-service symptomatology.  see Hickson, 12 Vet. App. At 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection).

In-service notation of a condition does not require medical evidence where the condition is of a type as to which a lay person's observation is competent.  However, although prong (3) does not require medical nexus evidence,  because it would not necessarily follow that there is a relationship between any present disability and the continuity of symptomatology demonstrated, medical evidence is required to demonstrate such a relationship unless such a relationship is one as to which a lay person's observation is competent.

A recent decision of the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court) clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a).  Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).  The Court explicitly rejected the argument that a dictionary definition of "chronic" should be used instead, noting that continuity of symptomatology in § 3.303(b) had no other intent than to afford an alternative route to service connection for specific chronic diseases.  Id.  

Notably, impotence is not a per se chronic disease listed in § 3.309(a), as such, not the type of condition that is subject to this continuity of symptomatology exception to the pleading requirements.

Moreover, the Veteran is not alleging, and the evidence does not otherwise suggest, that his impotence is directly or even presumptively related to his military service.  Rather, he is contending that it is the result of his service-connected low back disability - in particular, the treatment he has received in years past for this service-connected disability.  His claim, then, is predicated entirely on the notion of secondary service connection.  Consequently, this is the focus of this decision.

According to 38 C.F.R. § 3.310(a) and (b), service connection is permissible on this alleged secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability  Establishing entitlement to service connection on this 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).  Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation.  Allen, 7 Vet. App. at 448.  Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened.  Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991).

Thus, in order to establish entitlement to service connection for a claimed secondary disorder, there must be competent and credible evidence of a current disability; evidence of a service-connected disability; and competent and credible evidence of a nexus (causation or aggravation) between the service-connected disability and the claimed disability.  See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995).

Medical evidence is generally, though not always, required to associate the claimed condition with a service-connected disability.  Velez v. West, 11 Vet. App. 148, 158 (1998); McQueen v. West, 13 Vet. App. 237 (1999)

The evaluation of evidence generally involves a three-step inquiry.  First, the Board must determine whether the evidence comes from a "competent" source.  The Board must then determine if the evidence is credible, or worthy of belief.  Barr v. Nicholson, 21 Vet. App. 303 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible).  The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record.

Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience.  Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.  38 C.F.R. § 3.159(a)(2).  Lay evidence may be competent and sufficient to establish a diagnosis of a condition when:  (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (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.  Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).

In ascertaining the competency of lay evidence, the Courts generally have held that a layperson is not capable of opining on matters requiring medical knowledge.  Routen v. Brown, 10 Vet. App. 183 (1997).  In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation."  See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet).

Conversely, laypersons also have been found not to be competent to provide evidence in more complex medical situations.  See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever).

Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions.  Competent medical evidence may also include statements conveying sound medical principles found in medical treatises.  It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses.  38 C.F.R. § 3.159(a)(1).

Competency differs from credibility, and evidence must be both competent and credible to ultimately have probative value.  See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")).  See also Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted).  After determining the competency and credibility of evidence, the Board must then weigh its probative value in relation to the other relevant evidence.  Baldwin v. West, 13 Vet. App. 1, 8 (1999).  In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant.  Caluza at 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence").

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is resolved in favor of the Veteran.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102.

Specifically in this case, the Veteran contends that after receiving two epidural shots to relieve pain in his lower back, the third shot, which consisted of a double epidural injection because the previous injections had failed to ease his pain for very long, caused him to lose sensation and sexual drive.  Essentially, he believes the third shot caused lowered testosterone levels.  He as mentioned testified that those epidural injections were given in 2002, but it appears in actuality that some instead were provided in 2003.  No matter, he testified that, prior to them, regardless of whenever they actually occurred, he had a high sexual drive, versus since when he has had no urge to have sexual intercourse.

His post-service treatment records indicate he received the first epidural steroid injection in January 2002.  He received the second epidural steroid injection in approximately December 2002.  By May 2003 the record indicates he had received five or six epidural steroid injections.  He reported that, around October 2003, he started receiving hormone injections to address his low testosterone levels.  See June 2006 statement in support of claim, on VA Form 21-4138.  A July 2006 VA primary care report confirms he had low testosterone levels.  And a somewhat contemporaneous November 2006 VA psychological examination report notes his lack of sexual pleasure, which he linked to his epidural injections.  Another VA psychological examination report dated in November 2009 indicates he had been suffering from erectile dysfunction (ED) since 2002, which he continued to associate with his epidural injections.  Finally, the report of a February 2011 VA general medical examination reaffirms the diagnosis of ED.


He since has been provided a VA compensation examination in August 2012, however, for further medical work up and comment on these determinative issues of whether the treatment for his service-connected low back disability has caused or aggravated his impotence/ED.  Two opinions are required for secondary service connection claims:

1.  Is the claimed disorder "caused by" or "due to" the 
service-connected disability? AND

2.  Is the claimed disorder "aggravated by" the service-connected disability (Allen Aggravation)?

Evidence of baseline disability is necessary to establish entitlement to service connection for aggravation of a nonservice-connected condition by a service-connection condition (regulatory change effective from September 2006).  An opinion that something "is not related to" or "is not due to" does not answer the question of aggravation.  Allen, 7 Vet. App. at 448; 38 C.F.R. § 3.310(b).

Here, the VA examiner diagnosed the Veteran with both ED and hypogonadism.  The examiner further observed that the Veteran's ED started in approximately 2003, but that the hypogonadism had not previously been diagnosed.  After a comprehensive review of the claims file and the necessary testing and evaluation, this VA examiner ultimately determined the Veteran's impotence/ED is less likely than not proximately due to or the result of his service-connected condition.  The examiner's rationale noted that the Veteran had received an epidural for pain in his L5-S1 region and that his innervated genitals due to pudenal nerve damage could have been injured by the double injection; however, any injury to the nerves would not account for the lack of libido.  The examiner pointed out that the records indicated the Veteran had not had morning erections since 2002, which is an indication of low testosterone.  Indeed, testing done in association with that examination revealed extremely low testosterone levels, but which would not be caused by an epidural injection.  Finally, the examiner reiterated that the Veteran also had hypogonadism, which had not been previously diagnosed, and it instead, in the examiner's opinion, was the cause of the impotence/ED.

Based on this evidence, the Board finds that service connection for impotence/ED is not warranted.  Although there certainly is no disputing the Veteran has ED/impotence, the overall weight of the evidence is against a finding this condition is proximately due or the result of his service-connected low back disability, including especially the treatment in years past for it in the way of the epidural injections.  The August 2012 VA examiner, who was specifically requested to comment on this determinative issue of causation, concluded the Veteran's impotence/ED instead was the result of his hypogonadism, which in turn caused his low testosterone levels.  This opinion was based on a review of the claims file for the history of these disabilities, a history as provided by the Veteran himself, and an objective physical examination.  And although the Veteran indicated during his October 2012 Travel Board hearing that he would be consulting a doctor right after the hearing (later that same morning), in an attempt to also have this doctor comment on this determinative issue of causation, hopefully favorably, this apparently did not occur as the Veteran has not since submitted or even identified the existence of any such supporting medical nexus opinion.  So, as it stands, there is no competent and credible medical opinion refuting the VA examiner's unfavorable conclusion or otherwise suggesting the Veteran's impotence/ED is proximately due to or the result of his service-connected low back disability or treatment for it in the way of the epidural injections.

Regarding the additional question of whether there alternatively has been aggravation of the impotence/ED by the service-connected low back disability, the VA examiner's August 2012 medical opinion at least arguably does not expressly or outright refute or rule out this notion.  An etiological opinion has to be viewed in its entire context, however, and not characterized solely by the medical professional's choice of words.  See Perman v. Brown, 5 Vet. App. 237, 241 (1993); Lee v. Brown, 10 Vet. App. 336, 338 (1997).  This examiner completely disassociated the impotence/ED from the service-connected low back disability and the treatment for this disability, and one must also consider that a person is either impotent or not; there seemingly is no in between allowing for chronic worsening of impotence, even by a service-connected disability, since a person either has it or does not.

The Board additionally has considered the Veteran's lay statements and testimony in support of his claim and accepts that he is competent to report impotence as a symptom.  See Jandreau, supra; 38 C.F.R. § 3.159(a)(2).  However, he has not demonstrated the necessary knowledge or expertise to comment on the etiology of his impotence in relation to his service-connected low back disability and especially, as he is claiming, the treatment for it in the way of the epidural injections.  See Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue).  Here, the Board did indeed nonetheless request a medical nexus opinion on this determinative issue, and it was clearly unfavorable to the claim and remains unrefuted.

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.  See Kahana v. Shinseki, 24 Vet. App. 428 (2011).  Kahana cautioned that negative evidence, meaning actual evidence weighing against a party, must not be equated with the absence of substantive evidence.  See also Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc).  But, again, attribution of the Veteran's impotence/ED to treatment specifically for his service-connected low back disability in the way of the epidural injections is not the type of simple matter that is readily amenable to mere lay comment as it falls outside the realm of the competence of this type of testimony.


For these reasons and bases, the preponderance of the evidence is against this claim, in turn meaning there is no reasonable doubt to resolve in the Veteran's favor, and that this claim must be denied.  See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996).



ORDER

The claim for service connection for impotence/ED, including especially as secondary to the service-connected low back disability and treatment for it, is denied.



____________________________________________
KEITH W. ALLEN
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs