Citation Nr: 1311306 Decision Date: 04/05/13 Archive Date: 04/19/13 DOCKET NO. 10-40 410 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). 2. Entitlement to initial ratings in excess of 40 percent prior to September 8, 2009, and in excess of 60 percent thereafter, for service-connected urinary stress and urge incontinence status post three surgical procedures. 3. Entitlement to an initial rating in excess of 10 percent for service-connected gastroesphageal reflux disease (GERD), irritable bowel syndrome (IBS), and status post cholecystectomy. 4. Entitlement to an initial rating in excess of 30 percent for service-connected major depressive disorder. 5. Entitlement to service connection for memory loss and slowed response time claimed as residuals of an in-service stroke. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant, her spouse, two sons and daughter ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1988 to May 2009. These matters come before the Board of Veterans' Appeals (Board) on appeal from August 2009 and May 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In relevant part, in the initial August 2009 rating decision, the RO granted service connection for: urinary stress and urge incontinence status post three surgical procedures, initially evaluated as 40 percent disabling, effective June 1, 2009; chronic major depressive disorder and chronic pain disorder associated with medical and psychiatric factors, initially evaluated as 30 percent disabling, effective June 1, 2009; GERD, initially evaluated as 10 percent disabling, effective June 1, 2009; IBS, initially evaluated as noncompensable, effective June 1, 2009, and; status post cholecystectomy, initial evaluated as noncompensable, effective June 1, 2009. Additional evidence was received and the claims were reconsidered in a subsequent August 2009 rating decision, which continued initial disability ratings previously assigned. In a May 2010 rating decision, the RO found clear and unmistakable error in the August 2009 rating decision as to the assignment of a 10 percent evaluation for service-connected GERD and the assignment of separate noncompensable evaluations for IBS and status post cholecystectomy. The RO closed the separate noncompensable evaluations for IBS and status post cholecystectomy and combined them with the initial 10 percent evaluation assigned for GERD. Additionally, in the May 2010 statement of the case, the RO increased the initial rating assigned for service-connected urinary stress and urge incontinence status post three surgical procedures to 60 percent, effective September 8, 2009. As that grant did not represent a total grant of benefits sought on appeal, the claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 53 (1993). In August 2011, the Veteran, her spouse, and children testified at a Travel Board hearing before the undersigned Veteran's Law Judge. A copy of the hearing transcript is of record. From the date of the hearing, the record was held open for 60 days in order to allow for the submission of additional evidence for consideration. Additional evidence was submitted in October 2011, accompanied by a waiver of initial RO consideration. This evidence will be considered by the Board in adjudicating this appeal. See 38 C.F.R. § 20.1304 (2012). A review of the Veteran's Virtual VA electronic claims file is negative for additional information or evidence pertinent to the claims on appeal. The issues of entitlement to an increased initial rating in excess of 10 percent for GERD, IBS, and status post cholecystectomy; entitlement to an increased initial rating in excess of 30 percent for major depressive disorder, and; entitlement to service connection for memory loss and delayed response time claimed as residuals of an in-service stroke, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. At the August 2011 Travel Board hearing, the Veteran withdrew her appeal as to the issue of entitlement to a TDIU. 2. Prior to September 8, 2009, the Veteran's service-connected urinary stress and urge incontinence status post three surgical procedures was manifested by urine leakage requiring the changing of absorbent pads up to three times per day and use of an appliance; urinary frequency of one to two times an hour during the day and 1 to three times at night, and; and daily use of a catheter between one and three times per day. 3. Since September 8, 2009, the Veteran's service-connected urinary stress and urge incontinence status post three surgical procedures was manifested by urine leakage requiring the changing of absorbent pads more than four times per day and use of an appliance; urinary frequency of one to two times an hour during the day and up to six times at night, and; and daily use of a catheter three times per day. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal by the Veteran concerning the claim for entitlement to a TDIU have been met. 38 U.S.C.A. § 7105(b)(2) (West 2002 & Supp. 2012); 38 C.F.R. § 20.204 (2012). 2. Prior to September 8, 2009, the criteria for an initial rating of 60 percent, but not higher, for urinary stress and urge incontinence status post three surgical procedures have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Codes 7512, 7517, 7542 (2012). 3. Since September 8, 2009, the criteria for an initial rating in excess of 60 percent for urinary stress and urge incontinence status post three surgical procedures have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Codes 7512, 7517, 7542 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist In correspondence dated in March 2009, prior to the August 2009 rating decisions, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the RO notified the Veteran of: information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. She was informed of the types of evidence that could be submitted to support her claim. The March 2009 letter provided the Veteran with the notice required for the initial claim of service connection for urinary stress and urge incontinence status post three surgical procedures. Service connection was subsequently granted, and the Veteran appealed the initial rating assigned. In cases such as this, where service connection has been granted and an initial disability rating and effective date has been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Veteran bears the burden of demonstrating any prejudice from defective (or nonexistent) notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). That burden has not been met in this case, as neither the Veteran nor her representative has alleged such prejudice. VA has done everything reasonably possible to assist the Veteran with respect to her claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). Relevant service treatment records and post-service military, VA, and private treatment records have been associated with the claims file. All identified and available treatment records pertaining to the Veteran's urinary disability have been secured. Additionally, the Veteran was afforded VA examinations pertaining to her urinary stress and urge incontinence in March 2009 and March 2010. The reports of these examinations reflect that the examiners reviewed the Veteran's documented and reported past medical history, recorded her current complaints, conducted appropriate evaluations of the Veteran, rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record, and provided sufficient evidence to evaluate the disability. Neither the Veteran nor her representative have indicated that those examination reports are deficient with regard to the issue decided herein. Although the most recent VA examination pertaining to the Veteran's urinary stress and urge incontinence is dated in March 2010, the Veteran has not stated nor is there evidence indicating that there has been a material change in the severity of her urinary stress and urge incontinence disability since she was last examined in March 2010. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95 (April 7, 1995). The Board concludes that the examination reports are adequate for purposes of rendering a decision as to the claims decided herein. See 38 CF.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In short, the Board has carefully considered the provisions of the VCAA, in light of the record on appeal and, for the reasons expressed above, finds that the development of the issues decided herein have been consistent with said provisions. The Board is satisfied that any procedural errors in the originating agency's development and consideration of the claims were insignificant and nonprejudicial to the Veteran. The Veteran has been accorded ample opportunity to present evidence and argument in support of her claims. See 38 C.F.R. § 3.103 (2012). As noted above, the Veteran testified before the undersigned at an August 2011 hearing. Therefore, the duties to notify and assist have been met. Withdrawn - Entitlement to a TDIU An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the Veteran or by his or her authorized representative. 38 C.F.R. § 20.204. At the August 2011 Board hearing, the Veteran requested to withdrawal her claim for entitlement to a TDIU. As the Veteran has withdrawn her appeal as to the issue of entitlement to a TDIU, there remain no allegations of error of fact or law for appellate consideration. The Board, therefore, has no jurisdiction to review this issue. Increased Initial Ratings - Urinary Stress and Urge Incontinence Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2012); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2012); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2012); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2012). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged ratings" is required. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board will accordingly determine whether staged ratings are warranted. The Veteran contends that she is entitled to higher initial disability ratings for her service-connected urinary stress and urge incontinence status post three surgical procedures. Such disability has been rated by analogy under 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7599-7528, as 40 percent disabling prior to September 8, 2009, and as 60 percent disabling thereafter. Diagnostic Code 7528 contemplates malignant neoplasms of the genitourinary system, which have never been shown at any time in the Veteran's lifetime. Rather, it appears that her urinary stress and urge incontinence status post three surgical procedures is related to trauma and/or surgical treatment of trauma sustained during a vaginal childbirth where the child weighed in excess of 10 pounds, which resulted in significant pelvic trauma. The Veteran has also claimed that her urinary incontinence is related to neurological trauma related to an in-service stroke or an epidural injection received for surgical treatment during service. The Board also notes that findings on urinalysis have been found to be consistent with cystitis on multiple occasions. Under these circumstances, it appears that Diagnostic Codes 7512 for chronic cystitis of all etiologies, 7517 for injury of the bladder, and 7542 for neurogenic bladder, are the more appropriately applicable Diagnostic Codes. All of the aforementioned diagnostic codes direct the rater to rate the claimed condition as voiding dysfunction. Voiding dysfunction is rated under the three subcategories of urine leakage, urinary frequency, and obstructed voiding. 38 C.F.R. § 4.115a. Only the predominant area of dysfunction is considered for rating purposes. Id. For urine leakage, a 40 percent rating is for assignment when the wearing of absorbent materials must be changed two to four times per day. A 60 percent rating is for assignment with the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day. 38 C.F.R. § 4.115a, Diagnostic Codes 7512, 7517, 7542. For urinary frequency, the maximum 40 percent rating is for assignment with daytime voiding interval less than one hour, or; awakening to void five or more times per night. 38 C.F.R. § 4.115a, Diagnostic Codes 7512, 7517, 7542. The maximum evaluation for obstructed voiding, assigned for intermittent or continuous catheterization, is 30 percent. Id. A review of the record shows that the Veteran experienced urinary stress and urge incontinence since rectocele surgery in 2003. She underwent surgical procedures for urinary retention and stress and urge incontinence in July 2004, July 2006, and August 2007, without benefit. Urodynamic testing in October 2006 showed that the Veteran experienced a slow stream, mixed urinary incontinence, frequency, urgency, and incomplete emptying. She used panty liners that required changing two to three times a day due to urinary leakage with stress. In November 2007, private physical therapist and pain management physicians recommended a trial of treatment with a TENS unit for pelvic pain. In January 2008, it was recommended that she purchase a TENS unit and undergo trigger point injections for complaints of pelvic pain. Medical evaluation for a physical profile update in January 2008 shows that the Veteran experienced urinary frequency, stress and urge incontinence, and bladder outlet obstruction for which self catheterization was performed twice a day. During a May 2008 gynecological evaluation, it was noted that she experienced bladder leakage for which she was followed by a private physician. Additionally, that she had been receiving private physical therapy for one and a half years prior with a 20 percent improvement, subjectively. A May 2008 note pertaining to a Medical Board Evaluation shows that the Veteran's private urologist and physical therapist had placed significant physical restrictions on the Veteran. She experienced ongoing urge incontinence, occasional leakage, and incomplete voiding for which she performed self catheterizations twice a day. Urinary symptoms and abdominal pain had kept her on a limited physical profile for over 1 year. In September 2008, urinalysis was normal. In October 2008, the Veteran intermittently performed straight catheterization. She experienced several episodes of nocturia if she drank fluids past 7pm. In December 2008, urinalysis diagnosed a urinary tract infection and cystitis. Private pain management and physical therapy treatment notes show that in October 2008, she experienced increased bladder pain and urgency in the last several weeks with bladder spasm and episodes of urine leakage. She under went soft tissue mobilization procedures and intravaginal manual therapy. By February 2009, the strength of the Veteran's pelvic floor muscles had increased markedly. On service retirement examination in January 2009, a history of stress and urge incontinence, bladder outlet obstruction, and three bladder suspension surgeries, most recently in August 2007, with subsequent requirement for intermittent straight catheterization, was noted. Despite such notation, a review of genitourinary symptoms was said to be negative for dysuria, frequency, urgency, hesitancy, or foul odor to urine. She used intermittent straight catheterization and history of treatment for a urinary tract infection (UTI) was noted 1 month prior. A February 2009 private urology treatment note shows that the Veteran performed intermittent clean catheterization twice a day and urinalysis was positive for blood and leukocytes. The Veteran underwent a series of VA examinations while still on active duty in March 2009. It was noted that she began self catheterization in October 2006 due to bladder obstruction. She continued to self catheterize three times a day. She wore absorbent pads which she changed three to four times a day. She had significant urgency and experienced stress and urge incontinence. Her urinary frequency was every one to two hours during the day and nocturia one to three times a night. She denied any hematemesis or history of urinary tract stones. She experienced UTIs once every three months, which did not require hospitalization or parenteral antibiotics. Treatment included physical therapy for pain management since 18 months prior with limited benefit. The examiner diagnosed urinary stress and urge incontinence status post three surgical procedures with significant effects on the Veteran's occupation. As to her activities of daily living, such diagnosis had no effect on shopping, feeding, bathing, dressing and grooming; mild effects on chores, and driving; moderate effects on exercise, sports, recreation, and traveling, and; severe effects on toileting. The Veteran was scheduled to retire from active service in May 2009. Post service-treatment notes show that in September 2009, the Veteran complained that her urinary condition was interfering with employment. In an August 2009 statement, a private urologist indicated that the Veteran had a long history of bladder dysfunction since an unsuccessful anti-incontinence procedure with two additional unsuccessful surgical procedures in an attempt to help her bladder symptoms. Her symptoms included chronic bladder spasms, incomplete emptying, nocturia, urge incontinence, and frequency. Her post-void residuals were chronically elevated at about 250 cc's. She catheterized herself three times a day and still leaked large amounts of urine at times. She sometimes leaked through her clothing. Ongoing treatment for control of her symptoms included physical therapy, behavior modification, and medications, however, bladder symptoms still affected her life greatly. A notice of disagreement was received from the Veteran on September 8, 2009, the effective date of the increased 60 percent evaluation. She stated that her urinary urge and stress incontinence status post three surgeries resulted her need to wear absorbent pads that required changing six times per day. A September 2009 VA treatment note shows that the Veteran continued to experience urinary incontinence and retention which required self catheterization three times a day. Treatment with medication had not helped her symptoms. An October 2009 private psychological treatment note indicated that despite self catheterization twice a day, the Veteran still soiled herself with urine due to post-void residuals. Medication had not helped her symptoms. She experienced difficulty sleeping due to nocturia, even with self catheterization prior to bedtime. An October 2009 VA urology note shows symptoms of slow stream, urge and stress incontinence, and urinary retention with worsening symptoms. She catheterized herself three times a day. Post void residuals were about 200 cc's. She wore pads that had to be changed six times a day and she had about two UTIs per year. Physical evaluation revealed some redundant skin around the urethral meatus, no significant prolapse, and post void residuals of 220 cc's. Diagnostic assessment was urinary incontinence and retention status post multiple genitourinary procedures. The same symptoms were noted during a November 2009 VA gynecological evaluation. A treatment plan could not be created due to lack of review of private urology treatment notes, however, interstim and/or an artificial urethra were possible forms of treatment. A January 2010 VA urology note showed that although the Veteran was not interested in further surgical treatment, she requested that she receive physical therapy with an outside provider. Four weeks of non-VA physical therapy was approved at PPT for pelvic floor strengthening due to urinary stress and urge incontinence. A February 2010 VA mental health treatment note showed that the Veteran had recently lost her job. She felt discriminated against due to frequent bathroom visits and medical appointments. A February 2010 private urology note shows symptoms of urge incontinence, incomplete emptying, frequency, nocturia, and urgency. She had recently started pelvic floor therapy and had not seen any improvement. Medication for control of bladder spasm with leakage was changed. She was catheterizing three times a day. Her physical therapist thought that an injection of steroids and local anesthetic may help with therapy, thus, she was given an injection in her left vaginal side wall. In April 2010, it was noted that she received trigger point injections monthly for the last two months which, in combination with physical therapy, helped to reduce her symptoms of urinary urgency, frequency, and incomplete emptying. A March 2010 VA urology note shows complaints of urinary retention, urgency, frequency, and some incontinence. Prior treatment included medication, three unsuccessful surgical procedures, and physical therapy on two prior occasions which reportedly helped quite a bit. She experienced urinary frequency and urgency, self catheterization three times a day, and urinary incontinence that required use of pads that she changed six times per day. Examination revealed post void residual of 186 cc's. She was adamantly uninterested in further surgical treatment or undergoing a urodynamic study to determine what her bladder function actually was. During the March 2010 examination, a history of cystitis, a urinary tract disease, was noted. It was noted that her urinary retention and stress and urge incontinence had worsened since the performance of three surgical procedures without benefit. At the time of examination, urinary symptoms included a slow, weak, or intermittent stream; urine retention with she self catheterization three times a day; stress and urge incontinence for which she wore an absorbent pad that required changing six to eight times per day, and; urinary frequency every one to two hours during the day and nocturia one to three times per night. She reported urinary residuals in the bladder with self-catheterization. She experienced UTIs two to three times a year but had no hospitalizations or required any parenteral antibiotics in the last year. She denied hematuria, history of urinary tract stones, neoplasm, renal dysfunction or failure, acute nephritis, hydronephrosis, and cardiovascular symptoms. Treatment included physical therapy, which included stretching and exercise procedures in an effort to strengthen and relax the pelvic floor to gain better control of the pelvic muscles and improve symptoms of incontinence, among other things. Physical examination revealed normal vaginal skin without signs of normal vaginal atrophy. The meatus was normal if not slightly larger than normal. There was some redundant skin around the urethral meatus. Introitus was normal. Speculum examination did not show a significant amount of anterior or posterior prolapse. Tissues appeared fairly stable and there was no evidence of erosion or foreign body. There was no tenderness on manual examination or pelvic floor muscle tenderness. Straight catheterization for a post-void residual revealed 220 cc's of clear yellow urine. Marshall's test prior to catheterization was negative. The examiner diagnosed urinary stress and urge incontinence status post three surgical procedures with significant effects on her occupational functioning as an escort at a secure facility due to her need for frequent bathroom breaks and to change protective garments. Effects on her usual daily activities ranged from none to severe. During the last 12 months, she lost less than 1 week from work due medical appointments and headaches. Although the condition interfered with her occupational duties to some extent, it was not likely to result in a complete inability to follow substantially gainful employment. In May 2010, urinalysis due to complaints of a UTI with dysuria was consistent with complicated cystitis. Treatment included antibiotic and pain medications. She was again diagnosed with a UTI in July 2010. At the August 2011 hearing, the Veteran and her husband and children testified that that her urinary disability is productive of nocturia up to six times a night on average; urinary frequency of every two hours during the day and nearly hourly at night, and; frequent self catheterization that resulted in UTIs two or three times a year. Self-catheterization kept her urinary frequency from being every hour. She continued to wear pads for urinary incontinence. Although her employer was aware of and accommodating of her urinary disability, she had used some sick leave due to late arrivals from urinary accidents and for medical appointments. Significantly, there was no indication that the Veteran's urinary disability resulted in any involvement or impairment of kidney function. Initial rating in excess of 40 percent prior to September 8, 2009 For the assignment of a 60 percent evaluation for urinary stress and urge incontinence under all potentially applicable Diagnostic Codes 7512 (chronic cystitis), 7517 (injury of bladder), and 7542 (neurogenic bladder), the evidence must show that the Veteran's urinary incontinence disability requires use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day. VA and private treatment records and examination reports dating prior to September 8, 2009, show that she has reported that her urinary incontinence has resulted in the changing of absorbent materials 4 times per day at most. Thus, the question on appeal is whether her urinary incontinence disability has required the use of an appliance or has renal involvement. After resolving any doubt in the Veteran's favor, the Board finds that the evidence does show that her urinary incontinence disability has required the use of an appliance throughout the duration of the claim, to include prior to September 8, 2009. In this regard, applicable Diagnostic Codes do not include a definition of an "appliance." Review of other Diagnostic Codes under ratings for Dysfunction of the Genitourinary System account for use of a catheter in disabilities rated on the basis of obstructive voiding. Additionally, Diagnostic Code 7516 accounts for a suprapubic cystotomy, which is a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow. Thus, the Board will assume for the sake of this case that the Veteran's use of a TENS unit for electro stimulation and strengthening of her pelvic floor muscles for reduction of symptoms of urinary stress and urge incontinence is considered an appliance as stated in the criteria for the assignment of a 60 percent disability rating on the basis of voiding dysfunction. In light of the foregoing, the Board finds that a 60 percent evaluation is warranted for the Veteran's urinary stress and urge incontinence for the period dating prior to September 8, 2009. The Board also finds that the evidence does not show that the Veteran's urinary stress and urge incontinence disability meets the criteria necessary for the assignment of an evaluation in excess of 60 percent at any time prior to or after September 8, 2009. In this regard, consideration has been given to the potential application of the various provisions of the Rating Schedule. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Higher ratings are available for renal dysfunction, however, the evidence of record does not show that the Veteran has experienced renal dysfunction at any time during the claim. Blood work and urinalysis throughout the claim have consistently shown normal kidney values and there is no indication that the Veteran has ever been diagnosed with renal dysfunction. Additionally, during the March 2009 and March 2010 examinations, the Veteran denied renal insufficiency, renal colic, and nephritis, as well as bladder stones, and hospitalization for her urinary disability. In light of these facts, contemplation of a rating for renal dysfunction is not warranted. Extraschedular Consideration Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extra-schedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Here, the Veteran's disability picture is not so unusual or exceptional in nature as to render the 60 percent rating currently assigned for the duration of the claim inadequate. The Veteran's service-connected urinary stress and urge incontinence is evaluated under voiding dysfunction, which criteria the Board has found to specifically contemplate the level of occupational and social impairment caused by this disability. 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Codes 7512, 7517, 7542. The Veteran's service-connected urinary disability has been manifested by the use of absorbent materials and appliance, urinary frequency, incontinence, and self-catheterization. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are congruent with the disability picture represented by the 60 percent disability rating assigned. Evaluations in excess of 60 percent are provided for certain manifestations of genitourinary disability, including for renal dysfunction, but as noted above, the evidence demonstrates that those manifestations have not been present at any time during the claim. The criteria for the 60 percent rating assigned reasonably describe the Veteran's disability level and symptomatology. Consequently, the Board concludes that a schedular evaluation is adequate and that referral of the Veteran's case for extra-schedular consideration is not required. See 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Codes 7512, 7517, 7542; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). To the extent that the Veteran's urinary disability interferes with her employability, such interference is addressed by the schedular rating criteria. In this regard, loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a), 4.1; Van Hoose v. Brown, 4 Vet. App. 361 (1993). In this case, the Veteran's urinary incontinence required her to change clothing and self-catheterize at work and wear adult incontinence aids, which she changed from four to six times per day, but there is no evidence that her urinary disability impairs her employment more than is reflected in the assigned 60 percent evaluation. Indeed, during the August 2011 hearing, the Veteran testified that her current employer is aware and accommodating of her urinary disability. Therefore, the Board finds that there are no attendant related factors such as marked interference with employment evidence, or an exceptional or unusual clinical picture, or of any other reason why an extraschedular rating should be assigned. For these reasons, the Board finds that referral of the case for extra-schedular consideration is not warranted. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as discussed above, the preponderance of the evidence is against a rating in excess of 60 percent at any time, and therefore, the doctrine is not for application as to the period dating since September 9, 2009. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (CONTINUED ON NEXT PAGE) ORDER Entitlement to a TDIU is dismissed. For the period dating prior to September 8, 2009, entitlement to an increased initial rating of 60 percent for service-connected urinary stress and urge incontinence status post three surgical procedures is granted subject to the criteria applicable to the payment of monetary benefits. Entitlement to an increased initial rating in excess of 60 percent for urinary stress and urge incontinence status post three surgical procedures is denied. REMAND The Board finds that additional development is warranted prior to adjudication of the Veteran's claims for entitlement to an increased initial rating in excess of 10 percent for service-connected GERD, IBS, and status post cholecystectomy; an initial rating in excess of 30 percent for service-connected major depressive disorder, and; service connection for memory loss and slowed response time claimed as residuals of an in-service stroke. Initial rating in excess of 10 percent for GERD, IBS, and status post cholecystectomy VA treatment records were most recently updated in February 2011. During the August 2011 hearing, the Veteran testified that she had received ongoing VA treatment as recent as 2 weeks prior for her service-connected gastrointestinal disabilities. As these records are relevant to the claims for increased ratings, ongoing VA treatment records should be obtained from the Omaha VAMC dating since August 2011. Additionally, the Veteran's testimony during the August 2011 hearing seem to suggest that her service-connected gastrointestinal disabilities may have worsened since the most recent VA examination in March 2010. Thus, an additional VA examination is warranted to determine the current nature and severity of her service-connected GERD, IBS, and status post cholecystectomy disabilities. Entitlement to an increased initial rating in excess of 30 percent for service-connected major depressive disorder Service treatment records submitted by the Veteran pertaining to in-service and post service treatment received at Offutt Air Base show that she received treatment at the mental health clinic from approximately January 2008 to January 2009, however, records direct the reviewer to "see AHLTA for encounter details." As these records date during the relevant rating period, they must be obtained for review. Additionally, in light of the need for obtainment of an additional mental disorders examination discussed below, and given that the most recent examination of the Veteran's service-connected major depressive disorder is dated in March 2010, approximately 3 years ago, the Board finds that an additional VA examination is necessary to determine the current nature and severity of the Veteran's service-connected major depressive disorder. Finally, the Board notes that during the August 2011 hearing, the Veteran and her husband testified that she attends weekly medical appointments where she receives a plethora of medications for stabilization of her psychiatric symptomatology. In this regard, ongoing VA psychiatric treatment records dating since February 2011 must be obtained for review. Entitlement to service connection for memory loss and delayed response time claimed as residuals of an in-service stroke The Veteran asserts that service connection is warranted for memory loss and delayed response time, which she claims are residuals of a stroke that occurred at an unknown time during active service. VA treatment records note that MRI of the Veteran's brain during active service in April 2009 revealed a right cerebellar density measuring 12x12 mm. VA and private physicians have subsequently opined that such finding is at least as likely as not indicative of a stroke during active service. Thus, the question on appeal is whether the Veteran has memory loss and delayed response time disabilities that are a result of or are otherwise related to an in-service stroke. In this regard, the Board notes that the record contains inconsistent findings as to whether the Veteran experiences memory loss and delayed response times disabilities. Neuropsychiatric evaluation in June 2010 revealed a score of 30 on Structured Inventory of Malingering Symptomatology (SIMS), which revealed endorsement, in relevant part, of illogical or highly atypical neurological symptoms and symptoms of memory impairment that are inconsistent with patterns seen in brain dysfunction or injury. Similarly validity indicators on the PAI corroborated a tendency of the Veteran to portray herself in especially negative or pathological manner, which may reflect deliberate distortion of her clinical picture. Overall, PAI responses reflected much greater impairment than was reported or demonstrated during the interview, thus, testing results were considered invalid. Responses on a MoCA screen of neurological functioning yielded a score of possible cognitive impairment in the areas of delayed recall and language problems. On a direct measure of accuracy around reported symptomatology, the Veteran's response s were consistent with a significant degree of intentional exaggeration. Similarly, on a validity indicator of a wider personality functioning scale, her responses revealed a pattern of presenting herself in an overly negative light, to the extent that the overall measure was invalidated. It was likely that the Veteran was in emotional distress and wished for others to take notice. Unfortunately, the lack of forthrightness regarding symptoms during evaluation made it difficult to clearly identify the specific nature of the distress and possible impairment. Leading to further diagnostic uncertainty was the impact that a possible stroke may or may not have had on her emotional functioning. It was noted that mood problems are not uncommon following a stroke and the Veteran reported some changes in her cognitive functioning although it was unclear when the stroke occurred. Additionally, testing with MoCA was suggestive of some cognitive problems. It was noted that perhaps follow-up neurocognitive testing may shed more light on underlying cognitive issues once her psychiatric issues are optimally managed. On VA examination only one month later in July 2010 to assess memory loss, the examiner stated that following discussion with the neuropsychiatric specialist who conducted the June 2010 neurocognitive evaluation, a diagnosis of cognitive disorder not otherwise specified could not be confirmed. Further, invalid responses to tests given during neuropsychological testing would make further testing unreliable. There was no diagnosis of cognitive disorder not otherwise specified because diagnosis could not be established in the absence of confirming neuropsychological test results that would demonstrate cognitive impairment. Because of the questionable validity on neuropsychological testing in June 2010, there were no neuropsychological test results confirming the presence of a cognitive disorder, thus, there could be no assessment of memory, judgment, social interaction, orientation, motor activity, visual-spatial orientation, subjective symptoms, neurobehavorial effect, or communication and consciousness. In light of notation in the June 2010 neuropsychiatric evaluation report that "perhaps follow-up neurocognitive testing may shed more light on underlying cognitive issues once the Veteran's psychiatric issues are optimally managed," the Board finds that now that it is nearly three years later, an additional neuropsychiatric examination in necessary to determine whether the Veteran has current memory loss and delayed response time disabilities that are caused by or otherwise related to an in-service stroke prior to adjudication of the claim. Additionally, the Board notes that the Veteran is currently in receipt of a 30 percent evaluation for service-connected major depressive disorder, which encompasses mild memory loss symptomatology. Speech impairment is also a symptom contemplated by the Schedule of Ratings for Mental Disorders. Additionally, a review of the record shows that while the Veteran did not specifically complain of memory loss or delayed response time until statements were received for her and her husband in June 2010, post-service treatment records do show reports of "mental fogginess" associated with Topamax medication for prevention of migraine headaches for which service-connection is currently in effect, and decreased mental alertness associated with sleep medication prescribed for sleep impairment associated with service-connected major depression. In this regard, if a Veteran has separate and distinct manifestations relating to the same injury, he or she should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). The evaluation, however, of the same manifestation under different diagnostic codes is to be avoided. 38 C.F.R. § 4.14 (2012). The Rating Schedule may not be employed as a vehicle for compensating a claimant twice or more for the same symptomatology, since such a result would overcompensate the claimant for the actual impairment of his earning capacity and would constitute pyramiding. See Esteban, citing Brady v. Brown, 4 Vet. App. 203 (1993). Ongoing VA and private treatment records, if any, pertaining to the Veteran's service-connected gastrointestinal and major depressive disorder disabilities and her claimed cognitive disabilities of memory loss and delayed response time should be requested and obtained, to include VA treatment records from the Omaha VAMC dating since February 2011. Accordingly, the case is REMANDED for the following action: 1. Contact any appropriate records repositories and request service treatment records pertaining to the Veteran and any treatment received at the Offutt Air Base Mental Health Clinic dating since January 2008 as alluded to in medical service treatment records obtained from Offutt Air Base, which contain notation of "See AHLTA for encounter details." If the RO/AMC cannot locate the requested service treatment records, the RO/AMC must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO/AMC must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 2. Contact the Veteran and request that she identify any additional medical treatment that she has received for her service-connected and claimed disabilities, VA and non VA, dating since 2011. Regardless of the Veteran's response, VA medical and psychiatric treatment records, if any, should be obtained from the Omaha Division of the VA Nebraska-Western Iowa Health Care System dating since February 2011. The RO/AMC should take appropriate steps to secure authorization necessary to obtain copies of any such treatment reports identified that are not currently of record and advise the Veteran that she may submit these records herself. If the RO/AMC is unable to obtain any records identified, the Veteran and her representative should be notified in order to allow them to submit those records for review. 3. Thereafter, schedule the Veteran for an appropriate VA examination to determine the nature and severity of her service-connected GERD, IBS, and status post cholecystectomy disabilities. Any and all studies, tests and evaluations deemed necessary by the examiner should be performed. Following examination of the Veteran and review of the claims file, to include any relevant records in Virtual VA, the examiner should identify all currently present gastrointestinal conditions, to include her service-connected GERD, IBS, and status post cholecystectomy disabilities. The examiner should specifically state whether the Veteran's IBS is productive of severe symptoms including diarrhea or alternating diarrhea and constipation, and whether there is more or less constant abdominal distress. The examiner should also indicate whether colitis, malnutrition, anemia, general debility, or malabsorption are related to the Veteran's GERD, IBS, and/or status post cholecystectomy, and if so, their severity. Also, please indicate the effect of these conditions on the Veteran's daily life and occupation. 4. Schedule the Veteran for a neuropsychiatric examination to determine the nature and severity of her service-connected major depressive disorder and whether she suffers stroke residuals of memory loss and delayed response time. Any and all studies, tests and evaluations deemed necessary by the examiner should be performed. The examiner should offer an opinion as to whether the Veteran describes any symptomatology in regard to her claimed stroke residuals of memory loss and delayed response time that is not attributable to her already-service connected major depressive disorder and/or stroke residual of migraine headaches or medications (Ambien/Topamax) taken for those disabilities. If so, the examiner should offer an opinion as to the etiology of those symptoms, to include commenting on whether they are attributable to a known clinical diagnosis, to include a left cerebellar infarct measuring 12x12mm noted on MRI of the brain in April 2009. If the examiner cannot identify a disease or disability which causes the reported memory loss and delayed response time symptoms, the examiner should so state. If a disease or disability is identified, the examiner should specifically comment on whether it is at least as likely as not that such disability had its onset during a period of active service, or is related to any event or injury in service, to include incurrence of a cerebellar infarct at an unknown time during active service. The examiner should acknowledge the Veteran's and her husband's and children's contentions of record as to the nature, etiology, and date of onset of her claimed memory loss and delayed response time disabilities. The examiner should provide a rationale for any opinion rendered and should attempt to reconcile any contradictory evidence of record. If the examiner is unable to offer any of the requested opinions, it is essential that he/she offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2011). The Veteran is hereby notified that it is her responsibility to report for the examinations scheduled in connection with this REMAND and to cooperate in the development of her case. The consequences of failure to report for a VA examination without good cause may include denial of her claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 5. After the development requested has been completed, review the examination reports to ensure that they are in complete compliance with the directives of this REMAND. If the examination reports are deficient in any manner, the RO/AMC must implement corrective procedures at once. 6. Thereafter, readjudicate the issues on appeal. If the benefits sought on appeal are not granted, issue a supplemental statement of the case with consideration of all applicable Diagnostic Codes, and afford the Veteran and her representative an opportunity to respond. Thereafter, the case should be returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs