Citation Nr: 1314699 Decision Date: 05/03/13 Archive Date: 05/15/13 DOCKET NO. 06-24 144 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a back disorder. 2. Entitlement to service connection for a urogenital disorder. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R.N. Poulson, Counsel INTRODUCTION The Veteran served on active duty from April 1983 to April 1986 and had subsequent unverified Reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. In March 2004, the RO denied entitlement to service connection for a gynecological condition, a back condition, and entitlement to TDIU. In June 2005, the RO confirmed and continued the March 2004 decision. The urogenital claim has been recharacterized as noted on the title page to better reflect the medical evidence of record and the Veteran's contentions. In July 2010, the Veteran testified before the undersigned Acting Veterans Law Judge at the RO. A copy of the transcript has been associated with the record. In September 2011, the Board remanded the case for further development, to include scheduling a VA examination. At the beginning of the appeal, the Veteran was represented by the American Legion. In a March 2010 VA Form 21-4138, the Veteran appointed the Disabled American Veterans as her representative, thereby revoking the earlier power of attorney. The issues of entitlement to service connection for a urogenital condition and entitlement to TDIU 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. FINDING OF FACT A preponderance of the evidence weighs against a finding that any currently diagnosed back disability had its onset in service, was manifested to a compensable degree within one year after service, or is otherwise causally or etiologically related to service, to include any event or incident therein. CONCLUSION OF LAW The criteria for service connection for a back disorder have not been met. 38 U.S.C.A. §§ 1110, 5103, 5013A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's 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 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). The VCAA notice 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; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable AOJ decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). A post-adjudication notice letter dated in March 2005 complied with VA's duty to notify the Veteran with regards to the service connection issue addressed herein. Specifically, this correspondence apprised the Veteran of what the evidence must show to establish entitlement to the benefit, what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. In addition, notice regarding a disability rating and an effective date was provided to the Veteran in a February 2008 notice letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Although the required notice was not provided until after the Veteran's claim was initially adjudicated, the claim was subsequently readjudicated in May 2009, April 2010, and August 2012 supplemental statements of the case, thereby correcting any defect in the timing of the notice. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). No further corrective action is necessary. The Board also finds that VA has complied with its duty to assist the Veteran in the development of her service connection claim. VA has obtained service treatment records, private treatment records, VA treatment records, and records from the Social Security Administration (SSA). The AOJ also reviewed the Veteran's paperless Virtual VA claims file, a highly secured electronic repository that is used to store and review documents involved in the claims process. The Virtual VA claims file contains VA outpatient treatment records dated from October 2010 to August 2012. Otherwise, there are no additional documents in the Virtual VA file not already contained in the paper claims file. The Board acknowledges that treatment records from Dr. Ebardo and Dr. Ballot are not of record. In September 2008, the RO requested records from Dr. Ballot. The request was returned as undeliverable. The Veteran has stated that these records are unavailable because they have been destroyed. In September 2008 and December 2008, the RO requested records from Dr. Ebardo. No response was received. Therefore, in view of the foregoing, the Board concludes that further efforts to locate these treatment records would be futile. The Veteran underwent VA examinations in October 2009 and November 2011, with addendum opinions issued in November 2009 and December 2011; reports of these examinations are of record. In that connection, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA opinions obtained in this case, when considered together, are adequate. They are predicated on consideration of all of the pertinent evidence of record, to include statements regarding the incidents that allegedly led to the development of the Veteran's back disability, and document that the examiners conducted a full examination of the Veteran and review of the claims file and fully understood the questions posed by the AOJ. The Board is satisfied there was substantial compliance with its September 2011 remand order. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). In Bryant v. Shinseki, 23 Vet. App. 488, the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. During the hearing, testimony was solicited regarding the service incurrence of the Veteran's alleged back disability, continuity of symptomatology, the existence of a current disability, and a nexus between such disability and service. In addition, the acting VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Moreover, neither the Veteran nor her representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim and the Veteran, through her testimony, demonstrated that she had actual knowledge of the elements necessary to substantiate her claim for benefits. As such, the Board finds that, consistent with Bryant, the acting VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. There is simply no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case. Thus, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 20 Vet. App. 537 (2006); Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). II. Analysis Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131. Service connection connotes many factors but basically means that the evidence establishes that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisted such service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish direct service connection for the claimed disorder, generally, there must be competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Shedden v. Principi, 381 F.3d 1163 (1995). Lay evidence can be competent and sufficient to establish the elements of service connection 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. Jandreau, 492 F.3d at 1377. Certain chronic diseases (such as arthritis) may be presumed to have been incurred in service if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service; or if shown in service and at any time thereafter. 38 U.S.C.A. § 1112(a); 38 C.F.R. §§ 3.303(b), 3.307(a)(3); 3.309(a) (2012). With 'chronic disease' shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term 'chronic disease', whether as manifest during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Here, the Veteran has asserted entitlement to service connection for a low back disability, which she contends is due to her military service. Specifically, she claims to have injured her low back while carrying a rucksack during basic training. She contends that she further injured her back in a hard landing at parachute school. The Veteran maintains that she has had back problems since service. The DD 214 shows that the Veteran's military occupational specialty (MOS) was that of material control and accounting specialist. Her awards and medals include the Parachute Badge. Service treatment records show that the Veteran was treated for low back pain of five days' duration in May 1983. The pain radiated into the leg. She denied a history of back trauma within the previous 72 hours. She also denied paresthesias. Tenderness to palpation was noted upon examination. There was no edema and full range of motion. Straight leg raising was negative. The assessment was back pain secondary to ruck sack. Service treatment records do not reflect a back injury as a result of a parachute jump. There is no separation examination with respect to the Veteran's active duty service. However, an April 1989 Reserve enlistment examination revealed a clinically normal spine. Post-service private treatment records show that the Veteran was treated in June 1995 for neck pain, headaches, right elbow pain, and joint pain in the ankles and knee region. Her past medical history included a "question of tendonitis." Upon follow-up in August 1995, the doctor noted that the Veteran also complained of lower back pain with radicular symptoms down the left leg. A July 1995 MRI reportedly showed a small predominantly left sided posterior disc herniation at the L5-S1 level. (The Board notes that a copy of this report is not in the claims file.) The diagnosis was lower back pain "most consistent with lumbosacral radiculopathy secondary to a herniated disc with superimposed lumbosacral myofascial pain syndrome." The record establishes that the Veteran started working for the post office in 1996, at which point she began feeling numbness in her back and down her right leg. In June 1998, the Veteran was treated for back pain that radiated into her right leg. An MRI reportedly showed L5-S1 central and slightly left-sided herniation. (The Board notes that a copy of this report is not in the claims file.) The Veteran hurt her back in November 2001 while picking up a heavy tray of mail at work. At that time, she denied a history of pain in the lower back, left-sided. She did give a history of a lower back problem, but stated that her current pain was "very different" from the pain that she had previously experienced. She was diagnosed with degenerative disc disease and radiculopathy of the right lower extremity. Her doctor concluded that the Veteran's symptoms had a "causal relationship" to the November 2001 work-related injury. Private treatment records show that the Veteran underwent an anterior L5-S1 fusion in March 2003. A May 2003 VA treatment record indicates that the Veteran wanted to change her primary care to the women's clinic. At that time, she indicated that she was recovering from back surgery. The Veteran underwent a revision laminectomy in September 2003. She continued to suffer from low back pain. Physical therapy and several epidural injections did not help, and she was eventually prescribed methadone. During a December 2003 SSA examination, the Veteran attributed her current back problems to the November 2001 work-related injury and noted that her workers' compensation claim had been approved. Subsequently, a January 2004 determination granted disability benefits for the Veteran's back disability. The record of evidence contains a September 2003 letter from Dr. P.R.A., who performed both back surgeries. He noted that the STRs reflect a May 1983 back injury that resulted in five days of back pain, which resolved. He indicated that the Veteran was doing well until she re-injured her back while at work in November 2001. The doctor concluded that the Veteran had a preexisting back condition which might have made her more susceptible to reinjure her back in November 2001. Dr. P.R.A. reiterated his opinion in a November 2004. He acknowledged that the Veteran's symptoms improved after her in-service back injury, but stated that it was "possible" she had injured a disc in May 1983 and that it was "possible" the symptoms that occurred in 2001 had exacerbated a pre-existing injury. The Veteran filed her current service connection claim in September 2003. VA treatment records show that, in June 2004, the Veteran gave a history of back problems that had started during service. She claimed that her back was aggravated by the 2001 injury. She was diagnosed with osteopenia in September 2005. The Veteran was afforded a VA spine examination in October 2009. In his report, the examiner noted that the Veteran submitted a November 2004 letter from Dr. P.R.A., which reflected his opinion that it was possible that her current back problems were due to the original injury in 1983. As the examiner did not have the Veteran's claims file at the time of the examination, an addendum was provided in November 2009, after review of the claims file. In the addendum, the examiner noted that the Veteran had only one in-service report of back pain. He further noted that gynecological medical records from June 2001 mention a herniated disc, and that the Veteran had a workplace accident at the postal service in November 2001, when she referred to left side back pain which she had not experienced before. The VA examiner noted that the evidence shows that the Veteran had a herniated disc in 1998; however, since there was no documentation that she had a problem with her back between May 1983 and 1998, it was his opinion that her low back problems were not related to a single incident that occurred in the service and were not related to anything that occurred in the service. During the July 2010 hearing, the Veteran reported that Dr. P.R.A. told her that the in-service back problem made her more susceptible to her work-related back injury. As instructed by the September 2011 Remand Order, the Veteran submitted to another VA spine examination in November 2011. She related her 1983 injury and indicated that she had experienced back pain after a parachute jump. She reportedly was treated by acupuncturists and chiropractors in the early 1990's. She complained of constant pain localized to the lumbar region with radiation into the right lower extremity, and occasional right lower extremity numbness after prolonged standing. The examiner diagnosed lumbar spine degenerative joint disease status post laminectomy/fusion with right lower extremity radiculopathy. She opined that this disability is less likely as not (less than 50/50 probability) caused by or a result of the Veteran's service. She indicated that the 1983 injury was mechanical/muscular, as there was no indication of neurologic involvement, and that severity of the condition was mild and without expectation to progress further. She noted that there were no repetitive complaints of back pain/injury during service, and that the April 1989 examination was negative for any back condition. She also noted that the STRs did not corroborate a hard parachute landing. The examiner specifically considered Dr. P.R.A.'s opinion and concluded, based on the above, that there was no evidence of chronicity from the time of the 1983 injury to the first post-service back complaint in 1998. An addendum provided in December 2011 confirms that the examiner had reviewed the claims file before rendering an opinion. The record clearly shows that the Veteran currently suffers from a back disability. The record also supports a finding of in-service incurrence. The Veteran alleges, now, that she has had continuous problems with her back since the injury during service. However, after a review of all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran has not experienced continuous symptoms of back problems since shortly after separation. Furthermore, the Board concludes that her assertion of continued symptomatology since shortly after service, while competent, is not credible. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). A veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (when 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). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board notes that the Veteran's May 1983 in-service complaint of back pain, to which she now traces her current lumbar spine disability, is noted in her service treatment records, but upon orthopedic examination at her April 1989 Reserve enlistment examination the Veteran was found to have a clinically normal spine; no diagnosis of any back disability was made. The Veteran made no mention of a service injury when she sought treatment for back pain in 1995 and 1998. Nor did she reference any service injury when she first sought treatment from the VA in May 2003 or during her December 2003 SSA examination. In fact, the medical records clearly establish that the Veteran injured her back in a November 2001 post-service work-related injury. Indeed, Dr. P.R.A. determined at that time that the Veteran's symptoms were causally related to the work-related injury. Histories reported by the Veteran for treatment purposes are of more probative value than the more recent assertions and histories given for VA disability compensation purposes. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). It is entirely reasonable to assume that if the Veteran had, in fact, had back problems from 1986 until the 1990s, she would have mentioned such when seeking medical treatment, especially when seeking treatment for the back. Accordingly, after weighing the lay and medical evidence pertinent to the claim, the Board finds that the preponderance of the evidence is against finding that the Veteran has experienced back problems since service. In summary, the Veteran did not report an in-service back injury to medical professionals until 2004. It was only after filing her service-connection claim in September 2003, 17 years after separating from service, that the Veteran alleged that she suffered from a back injury that occurred in service. For these reasons, the Board does not find the Veteran's account of experiencing a continuity of back problems since service to be credible. Importantly, the October 2009 and November 2011 opinion, with the November 2010 and December 2011 addendums, is evidence that weighs against the Veteran's claim. This evidence is sound because it is based on a review of the Veteran's history of back injury during service, her post-service back injury, and the Veteran's personal statements about her back. The examiners also offered a rationale for the opinion that the Veteran's back disability is not related to service. While this, in and of itself, is not a sufficient reason to find against the Veteran's claim, it is a factor to be considered in determining the etiology of the current back disability. Furthermore, the opinion rendered by Dr. P.R.A. in 2003 and 2004 suggesting that the Veteran's current back disability is related to an in-service back injury is of no more than minimal probative value, as it is speculative in nature (e.g., "possible"). A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). Accordingly, the Board finds that this medical opinion is outweighed by the VA medical opinions. The Veteran did not assert entitlement to disability benefits for her back for approximately 17 years after service. She did not seek treatment for any problems with her back until 1995, nearly ten years after her separation from service. The Court has indicated that normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service, is probative evidence against the claim. See Maxson v. Gober, 230 F.3d 1330, 1333(Fed. Cir. 2000). Thus, service connection for a back disability is not warranted on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309. The Board acknowledges that the Veteran has reported that she first experienced symptoms of back pain during service, that she sought treatment for back pain during service, and that she has had back problems since service. The Veteran is competent to provide testimony concerning factual matters of which she has first-hand knowledge (i.e., experiencing symptoms either in service or after service). See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). However, as a layperson, lacking in medical training and expertise, the Veteran cannot provide a competent opinion on a matter as complex as the etiology of her current lumbar spine disability and her views are of no probative value. And, even if her opinion was entitled to be accorded some probative value, it is far outweighed by the VA examiners who thoroughly reviewed the claims file, examined the Veteran, and concluded that her back disability was not related to service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Based on a review of the foregoing evidence and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a back disorder. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for a back disorder is denied. REMAND The Board finds that further evidentiary development is necessary before a decision can be reached on the merits of the urogenital claim. Urogenital The Veteran contends, and service treatment records confirm, that while on active duty she experienced abdominal pain, burning urination, and urinary frequency. These symptoms were associated at that time with repeated yeast infections. She maintains that her in-service symptoms are related to her current diagnosis of interstitial cystitis rather than her yeast infections. Post-service private and VA treatment records dated from July 1989 to August 2012 establish that the Veteran has received ongoing treatment for pelvic pain/pressure, burning/painful urination, and painful intercourse. These records contain diagnoses for the following gynecological and urological disorders: sterile cystitis, interstitial cystitis, trigonitis, vestibulitis, Reiter's syndrome, urethritis, leiomyomatous uterus, urethral hyperesthesia, Grade 2 rectocele, lower urinary tract symptoms (LUTS), adenomysis, vaginal atrophy, and pelvic floor spasm. The Veteran was diagnosed with endometriosis in 2003, however, lab reports do not confirm this diagnosis. She underwent a total hysterectomy in 2004. In support of her claim, the Veteran has submitted a September 2004 letter from her private physician. The doctor indicated that he had reviewed the Veteran's service treatment records, and that an entry from May 1983 shows that the Veteran had a history of lower abdominal or pelvic pain associated with dysuria and frequency. He indicated that interstitial cystitis can begin with relatively mild symptoms and can slowly crescendo over time. He opined that this may very well be the case for the Veteran, after speaking with the Veteran and reviewing her service treatment records, which also included a March 1985 notation of urethritis. Finally, he concluded that her present condition was probably linked to her time spent in the military. However, this examiner did not discuss the fact that the Veteran's in-service symptoms had been associated with yeast infections, and did not provide any discussion of her post-service treatment or progression of symptoms. The Veteran was provided with a VA examination in October 2009. This examiner diagnosed vulvitis, atrophic vaginitis, and interstitial cystitis, but did not provide an opinion as to whether the Veteran's in-service symptoms that had been associated with yeast infections were early manifestations of her current diagnosis of interstitial cystitis. In a May 2010 addendum, the VA examiner concluded that there "is no indication" of any significant pain during service that would indicate endometriosis. He explained that "[o]ne would expect that she would have had recurrent episodes of severe dysmenorrheal or dyspareunia during this time." He acknowledged that STRs document several episodes of vaginitis, but refused to offer a nexus opinion, noting that this is a common condition that affects all women. As instructed by the September 2011 Remand Order, the Veteran submitted to another VA gynecological examination in November 2011. This examiner opined that the Veteran's chronic interstitial cystitis is less likely as not (less than a 50/50 probability) caused by or a result of the vaginitis that she experienced during service. She explained that all in-service genitourinary complaints had been appropriately diagnosed as candidal vaginitis/monilla based on the presence of budding yeast, thick white discharge, and clue cells. She noted that the Veteran was diagnosed with interstitial cystitis between 1998 and 2003. The examiner acknowledged the insidious onset of interstitial cystitis, but noted that there was a 10 year time period between the Veteran's last in-service genitourinary symptom and the interstitial cystitis diagnosis. She opined that it is less likely as not that onset of interstitial cystitis occurred while in service. The Board finds the November 2011 VA examiner's report to be inadequate. Although she reportedly reviewed the file, she failed to consider the Veteran's various gynecological disorders aside from endometriosis and interstitial cystitis. Accordingly, this matter must be remanded for a new VA gynecological examination. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that VA must provide an examination that is adequate). As discussed above, service treatment records show that the Veteran reported frequent urination during service. She has continued to have complaints of frequency following her separation from service. In light of her continued symptoms, the Board finds that a VA urological examination and opinion regarding any nexus to service is required. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McClendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, there are outstanding treatment records that should be obtained on remand. On a VA Form 21-4142, dated in July 2008, the Veteran indicated that she had received medical treatment from Dr. Pollich. She included a partial street address and city, but no zip code. In correspondence dated in September 2008, the RO indicated that it needed "a complete mailing address to include ZIP code." (Emphasis in original). The RO requested that the Veteran complete a new VA Form 21-4142 so that treatment records from Dr. Pollich could be obtained. In October 2008, the RO received a VA Form 21-4142 that contained the same partial street address and city, as well as a zip code. The RO took no action on this VA Form 21-4142, and the May 2009 supplemental statement of the case contains no mention of either form. The Board notes that the Veteran reportedly received gynecological treatment from Dr. Pollich prior to being treatment by Dr. Klein (see July 2006 VA Form 9), and that Dr. Klein's records are the earliest post-service evidence of such treatment. Thus, the AOJ should request that the Veteran complete a new VA Form 21-4142 for the purpose of obtaining relevant treatment records from Dr. Pollich. TDIU With respect to the Veteran's TDIU claim, the Board notes that the Court held in Holland v. Brown, 6 Vet. App. 443 (1994), that a claim for a total disability rating based on individual unemployability due to a service-connected disability is "inextricably intertwined" with a rating increase claim on the same condition. Thus, the Veteran's TDIU claim must be deferred pending the outcome of her other claim seeking entitlement to service connection for a urogenital condition. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that she complete an appropriate release (VA Form 21-142) of her private treatment records from Dr. Pollich from April 1986 to October 1998. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Schedule the Veteran for a VA gynecological examination. The claims folder, to include a copy of this Remand, must be reviewed in conjunction with the examination. All necessary tests should be conducted and all clinical findings reported in detail. The examiner is to opine as to whether it is at least as likely as not (a 50 percent or greater probability) that any currently diagnosed gynecological disorder is related to symptoms she experienced during service. A full and complete rationale for all opinions expressed must be provided. If the examiner determines that he/she cannot provide an opinion on the issue at hand without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be rendered because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. See Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). (The agency of original jurisdiction should ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.) 3. Schedule the Veteran for a VA urology examination. The claims folder, to include a copy of this Remand, must be reviewed in conjunction with the examination. All necessary tests should be conducted and all clinical findings reported in detail. The examiner is to opine as to whether it is at least as likely as not (a 50 percent or greater probability) that any currently diagnosed urological disorder is related to symptoms she experienced during service. A full and complete rationale for all opinions expressed must be provided. If the examiner determines that he/she cannot provide an opinion on the issue at hand without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be rendered because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. See Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). (The agency of original jurisdiction should ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.) 4. Thereafter, readjudicate the urogenital and TDIU claims. If either benefit sought remains denied, issue a supplemental statement of the case and provide the Veteran and her representative the requisite period of time to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. No action is required of the appellant unless she is notified. The Veteran and her representative have the right to submit additional evidence and argument on the 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). ______________________________________________ M.W. KREINDLER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs