Citation Nr: 1313563 Decision Date: 04/23/13 Archive Date: 05/03/13 DOCKET NO. 05-15 960 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for insomnia as a distinct ratable entity, to include as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a stomach disability, to include as secondary to service-connected PTSD. 3. Entitlement to service connection for a respiratory disability. 4. Entitlement to service connection for cellulitis of the left foot and groin. 5. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to medication for service-connected disease or injury. 6. Entitlement to special monthly compensation (SMC) due to loss of a creative organ. REPRESENTATION Veteran represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Shana Z. Siesser, Counsel INTRODUCTION The Veteran served on active duty from March 1966 to March 1970. These matters come before the Board of Veterans' Appeals (Board) from multiple rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In January 2005, the RO denied the Veteran's applications to reopen his claims for (1) entitlement to service connection for cellulitis with lymphangitis, left foot, and lymphadenitis, left groin, and (2) PTSD. The RO also denied claims for entitlement to service connection for a stomach disability, insomnia, migraines, and impotence, and entitlement to SMC due to loss of use of a creative organ. In July 2005, the Veteran testified during a hearing before a decision review officer (DRO) at the RO; a transcript of that hearing is of record. In June 2006, the RO denied an application to reopen the claim for service connection for pneumonia and pharyngitis (now claimed as respiratory disability). This case was previously before the Board in January 2011, at which time the Board reopened the claims of service connection for PTSD, a respiratory disorder, and cellulitis of the left foot and groin. At that time, the Board also remanded the claims of entitlement to service connection for PTSD, a respiratory disability, left leg or groin cellulitis, a stomach disability, insomnia, erectile dysfunction/impotence, and entitlement to SMC due to loss of use of a creative organ for additional development. The RO has complied with the remand directives. In a September 2012 rating decision, the RO granted service connection for depression. A January 2013 rating decision recharacterized the issue as service connection for PTSD and depression, and assigned ratings of 30 percent disabling from June 2, 2004 and 50 percent disabling from May 12, 2011. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The issues of entitlement to service connection for erectile dysfunction and SMC for loss of use of a creative organ 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. The Veteran served in Vietnam and is presumed to have been exposed to herbicides. 2. The Veteran does not have an independent diagnosis of insomnia, apart from the insomnia that is a symptom of his service-connected PTSD and depression. 3. The Veteran does not have a stomach disorder that was manifest during service, or was aggravated by any incident of service, or is secondary (causation or aggravation) to his service-connected PTSD. 4. The Veteran does not have a respiratory disorder that was manifest during service, or was aggravated by any incident of service. 5. The Veteran's currently diagnosed skin disorder was not manifest in service, nor is it attributable to any incident of service. CONCLUSIONS OF LAW 1. Insomnia was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. Insomnia, a separate ratable entity, is not proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310 (2012). 3. A chronic stomach disability was not incurred in, or aggravated by, active service, and is not proximately due to or the result of a service connected disease or injury. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 4. A chronic respiratory disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 5. A skin disorder, to include cellulitis of the left foot and groin, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) VA must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ), as was done in this case. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For claims pending before VA on or after May 30, 2008, 38 C.F.R. 3.159 was amended to eliminate the requirement that VA request that a claimant submit any evidence in his or her possession that might substantiate the claim. 73 Fed. Reg. 23,353 (Apr. 30, 2008). In compliance with the duty to notify the Veteran of what information would substantiate his claim, the Veteran was advised that VA used a Schedule for Rating Disabilities (Schedule) that determined the rating assigned and that evidence considered in determining the disability rating included the nature and symptoms of the condition, the severity and duration of the symptoms, and the impact of the condition and symptoms on employment. Here, the VCAA duty to notify was satisfied by way of letters sent to the Veteran dated in February 2006, March 2006, May 2011, and October 2012 that fully addressed all notice elements. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the service treatment records, VA outpatient treatment records and private medical records. Additionally, the Veteran was afforded VA examinations in June 2011, October 2012, and December 2012. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service connection claims Veterans are entitled to compensation from the DVA if they develop disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C.A. § 1110 (wartime service), 1131 (peacetime service). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d) (2012); Cosman v. Principi, 3 Vet. App. 303, 305 (1992). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection is permissible on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a) and (b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). But when there is aggravation, the Veteran is only compensated for the degree of disability (and only that degree) over and above the degree of disability existing prior to the aggravation. Id.; see also 71 Fed. Reg. 52744 -52747 (Sept. 7, 2006). The Veteran served in Vietnam and is presumed to have been exposed to herbicides. VA's Secretary has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See Notice, 67 Fed. Reg. 42600-42608 (2002); 75 Fed. Reg. 81332 -81335 (2010). Therefore, regardless of any herbicide exposure in Vietnam, because the Veteran has not been diagnosed with a condition included in 38 C.F.R. § 3.309(e), the presumptive regulation is unavailing. Competent and credible lay evidence may establish the presence of observable symptomatology and, in certain circumstances, may provide a basis for establishing entitlement to service connection. When, for example, a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh the lay testimony and make a credibility determination as to whether it supports service connection. See, e.g., Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a); see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, although claimants may be competent to provide the diagnoses of simple conditions, such as a broken leg, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc., they are not competent to provide evidence on more complex medical questions beyond simple observations. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (indicating lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional); 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 aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). Indeed, even if lay testimony is competent, should VA find it to be mistaken or lacking credibility, the Board may reject it as unpersuasive and, thus, not ultimately probative. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) see also Rucker v. Brown, 10 Vet. App. 67 (1997) and 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")). The Board may find a lack of credibility in, for example, conflicting medical statements or witness biases. Buchanan, 452 F.3d at 1337. The lack of contemporaneous medical evidence is also relevant; however, the mere lack of such evidence may not constitute the sole basis for discrediting the lay evidence. Id. Although the Veteran served during a period of war, he does not contend that the disorders for which he is seeking service connection were incurred during combat. Therefore, 38 U.S.C.A. § 1154(b) is inapplicable. 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, 53 (1990). Insomnia, secondary to PTSD The Veteran contends that he is entitled to service connection for insomnia, as secondary to his PTSD. As stated above, the Veteran is in receipt of service connection for PTSD. At the July 2005 RO hearing, the Veteran testified that he had been experiencing insomnia since service and only sleeps two to three hours per night. Post-service treatment records for his PTSD show sleep disturbance. The Veteran underwent a VA examination for his psychiatric disorders in December 2012. The examiner noted that the Veteran had problems with sleep, and opined as follows: "[T]he Veteran does not qualify for a separate insomnia diagnosis, since his problems with sleep are a symptom of his PTSD and depression disorders. Thus, no diagnosis of insomnia on a direct basis is warranted, since such a diagnosis is not given in cases where the Veteran has insomnia as a component of another mental health condition (PTSD and depression); and no diagnosis of insomnia is given as secondary to PTSD, since again, no such diagnosis is given in cases where the Veteran has insomnia as a component of another mental health condition (PTSD and depression). To this end, it is noted that the Veteran currently receives a 50 percent rating for his service connected depression and PTSD; and sleep impairment is actually listed among the symptoms to consider when evaluating the impairment caused by a service connected psychiatric disability. See 38 C.F.R. § 4.130. The Veteran is competent to report that he has sleep problems and the Board acknowledges that the Veteran has insomnia as a symptom of his mental health disorder. VA does not generally grant service connection for symptoms alone, without an identified basis for those symptoms. Here, VA has identified PTSD and depression as the associated disabilities and has granted service connection accordingly. Therefore, service connection cannot be granted for insomnia as a separate disability. VA obtained a medical opinion of record to address this question, but the examiner found that to the extent the Veteran had insomnia, it was a symptom of his already service-connected depression and PTSD. The regulations provide that the evaluation of the same disability under various diagnoses, a concept known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. This regulation is applicable in this case, since the Veteran is already service connected for depression and provided a rating for it, which specifically contemplates the Veteran's sleep impairment. Thus, to provide a separate rating for insomnia would be to essentially compensate the Veteran twice for the manifestations of a single disability. Thus, following a full review of the record and the preponderance of the evidence is against finding that the Veteran has a separate disability of insomnia, apart from his insomnia that is a symptom of his mental health disorders. Therefore, service connection for insomnia, as a distinct ratable entity, as secondary to PTSD and depression is denied. Stomach disability The Veteran contends that he is entitled to service connection for a stomach disability based on direct incurrence from service, as well as secondary to his PTSD. The Veteran's service treatment records show multiple complaints of digestive tract pain and discomfort, and a diagnosis of intestinal spasm in March 1967. In November 1969, he was seen for complaints of stomach pain. He was treated with Maalox(r). His November 1969 discharge examination shows a normal clinical evaluation of the abdomen and is negative for any stomach disorders. During the July 2005 RO hearing, the Veteran testified that during service, he experienced cramping and soreness in his stomach, He also stated that he experienced pain upon eating certain foods. He could not recall receiving a diagnosis of a stomach disorder, but was treated with antacids. The Veteran alleged that he continues to experience these symptoms through the present, although has not been diagnosed with any specific gastrointestinal disorder. The Veteran underwent a VA examination in June 2011. The examiner noted that the Veteran was seen for a "nervous stomach" in November 1969. The Veteran stated that, at times, his stomach gets "upset," but he denied nausea, vomiting, or diarrhea. The Veteran acknowledged occasional constipation, but denied melena or bright red blood in his stool, abdominal pain, and cramping. He treats his stomach pains with Tums(r), but takes no other stomach medications. A physical examination of the Veteran's abdomen was benign without organomegaly. No hernias or masses were noted. The examiner noted that the Veteran cries easily and cried during the examination. The examiner concluded that there was no evidence of a stomach disorder, and therefore, it was less likely than not related to the Veteran's service. The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Brown, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143- 44 (1992). The Board recognizes the Veteran's statements made in support of his claim. The Veteran is competent to provide testimony and statements concerning factual matters of which he has firsthand knowledge (i.e., experiencing gastrointestinal symptomatology both during and since service). Washington v. Nicholson, 19 Vet. App. 362 (2005). Further, under certain circumstances, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson, supra; Jandreau, supra. The June 2011 VA examination is adequate as it considers the Veteran's service treatment records, current complaints, and a current examination of the Veteran. In this case, the Board finds that the objective post-service clinical evidence of record, as evidenced by the Veteran's negative treatment records and the June 2011 VA examination report which reflects no diagnosis because there was no pathology to render a diagnosis, contradicts the Veteran's lay assertions regarding a current diagnosis of a stomach disorder. As such, the Board finds the Veteran's lay assertions in this regard are not credible. Therefore, the expressly contradicting negative clinical findings of record are of greater probative value than the statements of the Veteran and, thus, will be given more probative weight. To the extent that the VA examiner notes that the Veteran cried during the examination, the Board has considered whether the Veteran has a claim based on secondary service connection due to his mental health disorders. However, as the Veteran has only symptoms but no clinical diagnosis, his stomach pains would only be symptoms of the mental health diagnosis and not a compensable disorder. As stated above, without evidence of pathology, service connection is not warranted. We also note that functional bowel syndrome has not been identified. In reaching this determination, the Board has also considered the issues of chronicity and continuity of symptomatology. With respect to chronicity, the Veteran reported a history of stomach pain during and since service. However, as the Veteran's alleged stomach disability is not among the enumerated disorders of 38 U.S.C.A. § 1101 and/or 38 C.F.R. § 3.309, section 3.303(b) is not applicable. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Consequently, the Board finds that the most probative evidence establishes that he does not have pathology or disability. Accordingly, the Board finds that the preponderance of the evidence is against service connection for a stomach disability, and the claim must be denied. The Board has considered the doctrine of giving the benefit of the doubt to the Veteran, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2012), but does not find that the evidence is of such approximate balance as to warrant its application. Respiratory disability Service treatment records show that in March 1966, the Veteran was treated for viral pharyngitis. In May 1966, the Veteran was diagnosed with bronchitis. His November 1969 discharge examination showed a normal clinical evaluation of the lungs and chest. A January 2003 treatment record indicates that the Veteran reportedly had pneumonia in 1998. In July 2003, the Veteran presented with respiratory concerns secondary to "mold exposure in his house for an unknown time." He reported clear rhinorrhea, chest tightness, and shortness of breath for the prior year. In January 2006, the Veteran was diagnosed with acute bronchitis and a November 2008 treatment record shows the Veteran was treated for an upper respiratory infection. The Veteran underwent a VA respiratory examination in October 2012. The examiner reviewed the Veteran's treatment records, chest x-rays and CT scan reports, and pulmonary function tests (PFTs). The examiner found that the results of the Veteran's PFTs did not accurately reflect the Veteran's current pulmonary functions because there was no usable data due to poor patient effort. As a result, the examiner found no diagnosable lung disease. As noted above, in order to warrant service connection, the threshold requirement is competent medical evidence of the existence of the claimed disability at some point during a Veteran's appeal. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim...even though the disability resolves prior to the Secretary's adjudication of the claim"); Degmetich v. Brown, 104 F.3d 1328 (1997); Brammer, supra. While the Board recognizes the Veteran's belief that he has a respiratory disorder, the competent medical evidence of record does not show the Veteran to have a diagnosis of a chronic disorder at any point during the period on appeal. The Board has considered the Veteran's contention that he has a respiratory disability. However, due to the patient's poor effort, no diagnosis could be made at the October 2012 VA examination and the Veteran's post-service treatment records contain no diagnosis of a current chronic respiratory disorder. Moreover, although he had bronchitis and pharyngitis during service, his discharge examination showed a normal evaluation of his lungs, chest, mouth, and throat. While the Board notes the Veteran's competence to report observed physical symptoms, such as shortness of breath, as a lay person he has not been shown to be capable of making medical conclusions, to include diagnosing a current respiratory disability. Therefore, the Board affords far greater weight to the in-service and post-service medical professionals who have declined to find a diagnosis of a chronic respiratory disorder. See Jandreau, 492 F.3d at 1377. As the preponderance of the probative evidence is against finding a current diagnosis of a chronic respiratory disorder, the Veteran's claim is denied. Cellulitis of the left leg and groin/skin The Veteran's service treatment records show treatment for in a hospital for cellulitis with lymphangitis of the left foot, lymphadentitis of the left groin, and abscess with lymphangitis of the left foot. The record also shows that the Veteran was cured of these conditions when he was released from the hospital in November 1967. His November 1969 discharge examination shows a normal clinical evaluation of the skin. In July 2003, the Veteran complained of a flesh colored left lower leg lesion which he had for years. An examination showed there was a "small area of slightly rough, slightly crusty skin c/w healing lesion/auto necrosis." In November 2008, the Veteran was noted with hypopigmented circumferential lesions surrounded by mild erythemia of both ankles, diagnosed as tinea. The Veteran underwent a VA examination in June 2011. The examiner noted that the Veteran has had a rash on his legs for the past four years, but had no rashes prior to that time. He also noted that the Veteran was diagnosed with tinea corporis in June 2011. A physical examination showed no visible rashes on the legs, arms, or groin and no scarring. The examiner opined that tinea corporis, diagnosed in June 2010, is less likely than not related to the left foot cellulitis and adenitis of the left leg and left groin, as the current rash started four years prior. There is no competent evidence regarding specific etiology to the contrary of the June 2011 examiner's opinion. The Board finds the report fully adequate for the purposes of adjudication. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The examiner founded his opinion on an examination of the relevant medical records and of the Veteran, and with reference to general medical knowledge. As stated above, the Board has found that while the Veteran does not meet the criteria for presumptive service connection based on herbicide exposure, service connection on a direct basis as due to in-service herbicide exposure must be considered. Here, however, there is no competent evidence linking the Veteran's current skin disorders to his in-service herbicide exposure. The examiner noted, and the treatment records show, that his currently diagnosed tinea began four year prior, in 2008, and although the Veteran had a diagnosis of cellulitis during service, his skin was normal upon discharge from service and he has had no symptoms, diagnoses, or treatment for a skin disorder until 2008, more than 38 years after his discharge. See Maxon v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (holding that evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim.) Based on the treatment records and the current examination, the examiner determined that the Veteran's current skin problems were less likely than not incurred in, caused by, or related to the Veteran's in-service skin diagnosis. Furthermore, the record is devoid of any competent evidence supporting a link between the current disabilities and herbicide exposure. In reaching this decision, the Board notes that the Veteran has contended that his current skin conditions are related to military service. In this case, the Veteran's opinion, as a layperson, is not probative in light of the objective medical records and the VA examiner's medical opinion. There is competent evidence that the Veteran has a diagnosis of a skin disorder and had a skin disorder during his period of service. However, the most probative evidence establishes that the in-service cellulitis resolved without residuals, that the tinea was first manifest many years after service, and that there is no relationship between service and the post-service rash. As the more probative evidence is against finding a nexus between his current disorder and service, the benefit sought on appeal cannot be granted. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert, supra. ORDER Service connection for insomnia as a distinct ratable entity is denied. Service connection for a respiratory disorder is denied. Service connection for a stomach disorder is denied. Service connection for a skin disorder, to include cellulitis of the left leg and groin, is denied. REMAND The Veteran's claims of service connection for erectile dysfunction and SMC due to loss of a creative organ are remanded to obtain additional information. Regarding the Veteran's claim of service connection for erectile dysfunction, at the July 2005 RO hearing, the Veteran asserted that he experienced erectile dysfunction secondary to medication given to him by the VA. Alternatively, the Veteran stated that his ED may be due to scarring from a surgical procedure performed on his penis during service. In a December 2010 informal hearing presentation, the Veteran also argued that service connection was warranted on a direct basis. Specifically, the Veteran stated that he was diagnosed with "likely urethral stricture disease" for which he received treatment while in service. Service treatment records also show that a meatotomy was performed on his penis in January 1969. The Veteran's November 1969 discharge examination shows a right varicocele and hyposadis. An October 2005 record showed that the Veteran complained of erectile dysfunction for the prior 30 years. His current medical records show recent treatment for hypogonadism and erectile dysfunction. The Veteran underwent a VA examination in December 2012. The examiner opined that the Veteran's erectile dysfunction was not secondary to any medications taken for his PTSD and therefore, his ED is not caused by or a result of taking any medication for his PTSD. However, the examiner offered no opinion as to direct service connection or whether his ED was secondary to medications taken for any other service-connected disorder. Because it has long been held that the statutory duty to assist requires a thorough and contemporaneous medical examination, especially in cases where there exists ambiguities and uncertainties relative to the claimed disorder, the Board must remand the claim for clarification. See Shipwash v. Brown, 8 Vet. App. 218, 222 (1995); see 38 C.F.R. § 4.2 (if the findings on an examination report do not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes). In addition, the issue of entitlement to SMC is inextricably intertwined with the issue of entitlement to service connection for erectile dysfunction/impotence, because a grant of the latter benefit would impact whether the Veteran is entitled to SMC, and therefore must be remanded as well. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination as to the etiology of his erectile dysfunction. All necessary tests should be conducted. a. The examiner should indicate whether it is as least as likely as not (50 percent probability or more) that the Veteran's erectile dysfunction is related to any incident of service, including, but not limited to the in-service infection, meatotomy, or varicocele. b. The examiner must also indicate whether the Veteran's ED is due to any medication he is taking to treat his service-connected disorders. c. A complete rationale must accompany any opinion provided. d. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account along with the other evidence of record in formulating the requested opinion. 2. Then, readjudicate the claim, including entitlement to SMC based on use of a creative organ. If upon completion of the above action any benefit sought remains denied, the case should be returned to the Board after compliance with requisite appellate procedures. 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). ______________________________________________ H.N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs