Citation Nr: 1316507 Decision Date: 05/20/13 Archive Date: 05/29/13 DOCKET NO. 04-37 228 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a genitourinary disability, claimed as neurogenic bladder, to include as secondary to service-connected bilateral knee disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D. Bredehorst INTRODUCTION The Veteran had active service from February 1982 to February 1985. This claim comes before the Board of Veterans' Appeals (Board) on appeal of a December 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. The RO in St. Petersburg, Florida, where the Veteran later resided, certified these claims to the Board for appellate review. The Veteran testified at a Travel Board hearing held before the undersigned Veterans Law Judge at the RO in March 2008. In May 2008, November 2011, and December 2012 the Board remanded this matter for additional development. A review of the Virtual VA paperless claims processing system reveals no documents pertinent to this claim, which are not already in the claims file. FINDINGS OF FACT 1. Credible evidence of an in-service injury that resulted in a current genitourinary disorder has not been presented. 2. The Veteran is not shown to have a current genitourinary disability that is causally or etiological related to service or to service-connected bilateral knee disabilities. CONCLUSION OF LAW A genitourinary disability was not incurred or aggravated in service, and is not proximately due to, or the result of, or chronically aggravated by the service-connected bilateral knee disabilities. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION In this decision, the Board will discuss the relevant law that it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R."); and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. Duties to Notify and Assist Upon receipt and prior to consideration of most applications for VA benefits, VA is tasked with satisfying certain procedural requirements outlined in the Veterans Claims Assistance Act of 2000 (VCAA) and its implementing regulations. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The United States Court of Appeals for Veterans Claims (Court) has mandated that VA ensure strict compliance with the provisions of the VCAA. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA and its implementing regulations provide that VA must notify a claimant and his representative, if any, of the information and medical or lay evidence not previously provided to the Secretary that is necessary to substantiate a claim. As part of the notice, VA is to specifically inform the claimant and his representative, if any, of which portion of the evidence the claimant is to provide and which portion of the evidence VA will attempt to obtain on the claimant's behalf. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). These notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of disability; (3) a connection between service and disability; (4) degree of disability; and (5) effective date of disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006). The August 2004 and February 2008 letters satisfy the content requirements noted above. The RO provided the Veteran the required notice of the evidence and information necessary to substantiate his claim, the information required of him to enable VA to obtain evidence, and the assistance that VA would provide in obtaining supporting evidence. The RO also provided the Veteran all necessary information on disability ratings and effective dates. During the Veteran's March 2008 hearing, the undersigned Veterans Law Judge identified the issue on appeal and discussed evidence related to the claimed disability in service, including the need for a competent opinion regarding nexus and outstanding treatment records. Although Bryant v. Shinseki, 23 Vet. App. 488 (2010) was issued two years after the hearing in question, the Veteran has been apprised of what evidence would substantiate his claim and provided additional opportunities for its submission in remands dated in May 2008, November 2011 and December 2012. The VCAA notice letters also satisfy pertinent timing requirements. Notice under the VCAA must be provided a claimant prior to an initial unfavorable decision by the agency of original jurisdiction. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 119-20 (2004). The RO sent the second notice letter after initially deciding the Veteran's claim. The RO cured this timing defect by readjudicating this claim in a supplemental statement of the case issued in August 2012. Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007). VA is also to assist a claimant in obtaining evidence necessary to substantiate a claim, but such assistance is not required if there is no reasonable possibility that it would aid in substantiating the claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). The RO made reasonable efforts to identify and obtain relevant records in support of the Veteran's claim. 38 U.S.C.A. § 5103A(a), (b), (c) (West 2002). Specifically, the RO tried to secure and associate with the claims file all evidence the Veteran identified as being pertinent to the claim being decided, including service and post-service treatment records. The RO also afforded the Veteran a hearing before the Board, during which the Veteran testified as to the onset of his genitourinary disability, and VA examinations, during which examiners addressed the etiology of the genitourinary disability. The RO also obtained an addendum opinion addressing the etiology of the genitourinary disability. Merits of the Claim The Veteran contends that his genitourinary disability had its onset in service and, therefore is directly related to service. As an alternate theory, he asserts the disability is due to his service-connected bilateral knee disabilities. Since a preponderance of the evidence weighs against the claim, service connection for the claimed genitourinary disability is denied below on both direct and secondary bases. In deciding this claim, the Board has reviewed all of the evidence in the Veteran's claims file, both his physical claims file and electronic ("Virtual VA") claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by him or obtained on his behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service connection is granted if it is shown the Veteran suffers from disability resulting from an injury sustained or a disease contracted in the line of duty during active military service, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. To establish entitlement to direct service connection, there must be: (1) competent and credible evidence confirming the Veteran has the claimed disability or at least has at some point since the filing of the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). Secondary service connection shall be awarded when a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). Libertine v. Brown, 9 Vet. App. 521, 522 (1996); see also Reiber v. Brown, 7 Vet. App. 513, 515-16 (1995); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. See Barr v. Nicholson,21 Vet. App. 303 (2007) (the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In ascertaining the competency of lay evidence, lay persons are competent to provide opinions on some medical issues; their competency depends entirely on the specific disability at issue. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Specifically, lay evidence has been found to be competent with regards to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr, supra; see also Jandreau, supra; Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). However, laypersons also have been found not competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). The standard of proof to be applied in decisions on claims for Veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, he prevails. See Gilbert, supra. The preponderance of the evidence must be against the claim for benefits to be denied. Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran's service treatment records include a December 1981 medical history report that indicates there was no current or past history of frequent or painful urination. An examination of the GU system was normal. November 1984 laboratory test results revealed that the Veteran's urine was yellow and negative for occult blood. A November 1984 medical history report indicates no current or past history of frequent or painful urination. The associated medical examination report indicates an abnormal GU system noted as "circ", which was considered not disabling. A December 1984 statement indicates the Veteran declined having a separation examination and the medical officer that reviewed his records found that one was not required for separation. The Veteran's post-service treatment records include an April 2003 VA record that shows a review of systems was negative for genitourinary symptoms, including dysuria, frequency, hesitancy, hematuria and discharge. A July 2003 record notes the Veteran had a history of benign prostatic hypertrophy (BPH). A March 2004 VA follow up note contains a review of systems and indicates the Veteran did not have any genitourinary symptoms that included dysuria, frequency, hesitancy, hematuria and discharge. His BPH was stable. A May 2004 VA urology consult request shows the Veteran complained of progressive voiding problems. That same month he had a urology consult and his chief complaint was difficulty voiding. He had lower urinary tract symptoms (LUTS) but no hematuria or incontinence. The Veteran stated that the condition had been present since 1984. He was recently given hytrin. A June 2004 clinical pharmacy note shows that the Veteran's medical problems included benign prostrate hypertrophy with urinary obstruction. There was no past history of UTI, orolithiasis, GU cancer, GU surgery, or other history. The physical examination was normal for the scrotum, epididymus, cord, testes, penis, and rectum. A July 2004 VA urology note shows that the Veteran had a cystoscopy. On physical examination, there was no abnormality of the scrotum, penis, or rectum, and the prostate was non-obstructing. The impression was neurogenic bladder. A November 2004 VA urology note indicates the Veteran had persistent difficulty voiding despite use of Hytrin and that the cystoscopy essentially ruled out an obstructive prostate. In the Veteran's March 2008 hearing testimony, he stated that he did not receive treatment for this disorder in service or after service because he was too embarrassed, but he had been receiving treatment for the past 3 to 4 years. Up until the past 1 year period, he had problems with urinary incontinence. He stated that a doctor wanted to put him on another medication to reduce the prostate. His VA doctor did not link his neurogenic bladder to military service. The Veteran did not know what the link was but he told his physician that it started in service. It was noted during the hearing that the November 1984 separation examination indicated "CIRC" in block 34 and the Veteran was asked if it stood for circumcision. The Veteran's response was that it was not circumcision and that instead it was abnormal urinary system. When asked again what "CIRC" was he stated that he did not know the abbreviation. A June 2008 statement from the Veteran indicates he completed a 2 year nursing program in England before moving to the U.S in 1980. He was trained as a combat medic at Fort Sam Houston from April to May 1982. He alleged that he did not seek medical care because medics took care of their own medical problems. A May 2010 cystoscopy revealed a small prostate. The preoperative diagnosis was urinary retention. On September 2010 VA examination, the Veteran reported having urinary hesitancy since 1982 due to a series of falls during basic training. He reported that in 1982 he was passing blood in his urine as a result of falling down on a hard surface with his GU area -one time only. On examination, his testes, prostate, epididymis, spermatic cord, and scrotum were normal. A May 2010 cystoscopy revealed a small prostate. The opinion was that the Veteran's genitourinary disability was not related to his service-connected knee disability. The rationale was that according to medical literature chondromalacia of the patella is a localized process that involves pathological changes only of the cartilage of the patella. It is not a systemic process that affects other body tissues or organs. The examiner specifically noted that this condition does not affect the genitourinary system. The physician also noted that the Veteran did not mention any genitourinary issues on his separation examination in November 1984. In an October 2010 addendum, the examiner stated that the claims file was reviewed in its entirety. A November 2010 statement from the Veteran's ex-wife indicates that they met in London where they were both training to be nurses and that she has been a nurse for over 30 years. She stated that he was physically fit when he entered service. She recalled that he first started having a slow stream and frequent urination while in basic training due to falls during obstacle course training. She joined him when he was later transferred to Fort Hood and that by this time he was having more problems with frequent urination. He was going to the bathroom more frequently with a weak stream because he was unable to empty his bladder fully. The Board found the September 2010 VA examination opinion was incomplete and, therefore, remanded the matter in November 2011. In the remand directive, the examiner was also asked to state if there was any clinical or medical basis for corroborating or discounting the ex-spouse's credibility and instructed the clinician to include a complete rationale. In a November 2011 addendum opinion, the physician noted that service treatment records show that on the November 1984 separation the Veteran stated there were no urinary conditions past or present. VA evaluations by urology mention the cystoscopy and the use of medications to treat urinary complaints. On September 2010 VA examination, the GU worksheet mentions that the Veteran had problems in 1982 after falling down on a hard surface and had hematuria but no other visits for urology related issues. There was mention of the cystoscopy findings of a small prostate, weak stream along with hesitancy, urinary dribbling plus straining to urinate and that the Veteran was started on Flomax to replace Terazosin. The June 2011 statement from the Veteran's ex-spouse noted the Veteran had a "slow stream and frequent urination in the service". He opined that the Veteran's genitourinary disability did not begin during active service nor was it related to any incident of service. The rationale was that the service records had only one instance in 1982 in which the Veteran sustained a urological problem which was blood in the "issue" following a case of blunt trauma. However, the service records did not show this as a recurring issue resulting in a chronic condition. Furthermore, the Veteran had a separation exam that did not specify any active or ongoing urological issues. Therefore, no chronicity or residuals could be established for a urological issue. The examiner noted that while the Veteran and ex-spouse relayed the history of slow stream and frequent urination, causes such as caffeinated beverages, dehydration, and stress/anxiety could be alternative explanations instead of a urological issue. The examiner observed that urinary frequency, slow stream, and urinary hesitancy appeared relatively new - starting on or about 2006 based on the available records. The Veteran seemed to respond to the alpha blocker type of medications with an improvement in his symptoms. The examiner observed that this was a strong suggestion of a prostate related issue such that relaxation of this type of tissue will promote the flow of urine in a narrowed passageway. The Board again remanded the matter in December 2012 due to noncompliance with the earlier remand directive. It was noted that the Veteran and his former wife were trained in medicine and, for this reason, the examiner was instructed to consider their statements in whether the genitourinary disorder is related to service. The Board found that in providing an addendum, the examiner disregarded the Veteran's and former spouse's statements regarding subsequent continuity of genitourinary symptomotology and ruled out in-service incurrence on the basis that there was no recurrence. The remand also noted that in offering the negative opinion contradicting those of the Veteran and ex-spouse there was no challenge to their credibility. In February 2013, an addendum was provided that did not change the opinion. Rather, the physician clarified the underlying reasoning for the negative opinion and challenged the credibility of the statements regarding the in-service injury that led to in-service symptoms. The physician provided several reasons for finding that the Veteran's genitourinary disability is not related to his active service to include the documented genitourinary abnormality. He noted that the Veteran was never seen, evaluated, diagnosed or treated for any genitourinary disability while in the service. There are no service records showing any sick call visits that the Veteran sought treatment and was diagnosed with a genitourinary condition while in the service. Chronicity was not established while in service in that the Veteran did not receive ongoing care and treatment for the condition while in service. The separation history and physical examination forms of November 1984 did not record any problems with the genitourinary either from the Veteran or as noted on his examination report. He also noted that the Veteran reported being in good health. With regard the Veteran's alleged falls, the physician challenged the credibility of the Veteran's history of falls in service as being significant in the development of his genitourinary issues. The type of alleged trauma sustained, by history, did not translate into any demonstrable clinical finding then or later. The Veteran indicated that he sustained numerous falls in service while in basic training and that this was the etiology for his genitourinary disability, which started in service. However, the examiner noted that there was no salient event while the Veteran was on active duty of a sufficient magnitude to have caused any such problems. A fall or falls of such intensity would have resulted in definite neurological complications soon after the injury transpired. They would have included not only the presence of urinary complaints but also problems with defecation, motor/sensory problems of his lower extremities, spinal fractures for example would have been evidence and significantly compromised the ability of the Veteran's ability to perform his military obligations. However, they were not present. The examiner noted during the September 2010 VA compensation examination that the Veteran's statement was taken and that "in 1982 the patient was passing blood in urine as a result of the patient falling down on a hard surface with his GU area -one time only". However, had this been considerable trauma, external deformities of his penile and external genitalia along with bruising would have been present. The nature of the injury would have compelled the Veteran to seek treatment. He added that the Veteran did not have these problems as the injury was minor. Also, any injuries to the bladder area would have been seen in the cystoscopy and GU examination in 2004 had the damage been significant, but there were none present. This indicated to the examiner again that the Veteran had a minor condition from his fall to the GU area. The examiner also noted that the Veteran did not receive any treatment shortly after he left the military. The claims file only showed that it was approximately 20 years after service when he presented with urinary complaints. There are no prior records other than that detailing an earlier problem with the genitourinary condition. The examiner stated that the information from the November 2011 addendum was noteworthy and observed that by the service records, there was only one instance in 1982 in which the Veteran sustained a urological problem which was blood in the issue following a case of blunt trauma. However, examiner noted that the service records do not show this as a recurring issue resulting in a chronic condition. Furthermore the Veteran had a separation exam which did not specify any active or ongoing urological issues. Therefore no chronicity or residuals could be established for a urological issue. The examiner also noted that while the Veteran and spouse relay the history of slow stream and frequent urination, causes such as caffeinated beverages, dehydration, and stress/anxiety could be alternative explanations instead of a urological issue. The examiner commented that the issue of his urinary frequency, slow stream, and urinary hesitancy seems to be a relatively new one starting on or about 2006 from the VA records at hand; and the Veteran seems to respond to the alpha blocker type of mediations with an improvement in his symptoms. The examiner observed that this strongly suggested that there is a prostate related issue such that relaxation of this type of tissue will promote the flow. The physician commented that the statements from the Veteran and ex-spouse regarding an in-service genitourinary condition are not consistent with the known medical anatomy and physiology of the spinal cord nervous system. The ex-spouse's letter of November 2010 referenced problems with the Veteran having falls during obstacle course training. Following that he developed problems with his back and urinary complaints. Her statement would then open the issue of a contribution from the spinal nervous system to the development of his urinary issues in view of the back problems that were mentioned in that note. The area of the spinal cord that would influence the development of any genitourinary system would be that of the entire spinal cord. However, these nervous system tracts are in close proximity to other ones that affect the respiratory system activity, upper and lower extremities sensory motor functions, chest/abdominal sensation, bowel defecation capability, and erectile dysfunction to name a few. Therefore, the mentioned falls should have resulted in multiple areas of spinal cord being affected. The physician noted that consequently, deficits involving the urinary system alone would not be conceivable as the nerve tracts supplying the bowels, bladder, and upper/lower extremities are so closely aligned, but this did not transpire. Thus, despite what the Veteran and his former spouse stated, it is an anatomical impossibility that an isolated, discrete genitourinary situation developed independently. The other aforementioned systems would have to have been affected but were not. The physician also stated that the prior diagnosis of the Veteran's neurogenic bladder was at odds with the Veteran's given clinical history in service and afterwards. A neurogenic bladder was the loss of normal bladder function caused by damage to part of the nervous system. He observed that the damage can cause the bladder to be underactive, in which it is unable to contract and unable to empty completely, overactive, in which it contracts too frequently without being able to be inhibited or inability to coordinate bladder contractions with sphincter relaxation. Examples of factors leading to the development of this condition would include that of multiple sclerosis, tumors, birth defects, traumatic spinal cord injuries, or brain injury. The Veteran was first seen for his genitourinary complaints by a urology group in May 2004 and extended to January 2005. He received diagnostic testing consisting of voiding studies, urinalysis, PSA, cystoscopy, and an abdominal sonogram. Those tests led to the diagnosis of neurogenic bladder and he was prescribed medication as part of his treatment plan. The Veteran does not have any of those conditions arising from an in-service event that led to the diagnosis of neurogenic bladder. The Veteran's current genitourinary condition recently evaluated by a urology group in May 2010 still does not show any pathological features resulting from any trauma or injury. The Veteran had two cystoscopies that were normal. Had there been a residual from in-service traumatic events, this would have been detected by the evaluations in 2004 and 2010, but those examinations were normal. Therefore, it is more conceivable that some other factor(s) are responsible for the Veteran's genitourinary issues than what happened in service. The Board finds the March 2013 addendum to be very thorough in addressing not only the etiology of the claimed disability but in addressing the assertions and credibility of the Veteran and ex-spouse from a medical perspective. In doing so, he found their reports not credible regarding the reported injuries causing the onset of symptoms and continuation of symptoms during service. His application of medical principles, knowledge of anatomy and physiology, and references to pertinent medical evidence of record in support of his opinion is more credible and probative than the Veteran and his ex-wife's statements despite his medic training and her nursing experience. The VA physician also offered other factors that could have led to the Veteran's urinary symptoms such as caffeinated beverages, dehydration, and stress/anxiety. In terms of weighing the probative value of her statement against that of the VA physician, the Board finds the wife's statement to be less probative as to the etiology of the claimed disability since provided no medical basis for asserting that the Veteran had urinary symptoms after in-service injuries. Although the Veteran is competent to report his symptoms, his statements regarding in-service injury and symptoms that continued during and after service, are not credible in light of his denial of urinary symptoms on the separation medical history report, and VA treatment records in 2003 and 2004 in which he denied having past or current genitourinary symptoms. It also lacks credibility that the Veteran would endure experiencing symptoms that were very embarrassing to him, such as wetting himself, for 20 years before seeking treatment. Furthermore, under Walker, service connection based on continuity of symptomatology is only applicable when the Veteran has one of the "chronic" diseases specifically enumerated in 38 C.F.R. § 3.309(a) and neurogenic bladder is not among the listed disorders. Hence, the Board concludes that a preponderance of the evidence is against finding that the claimed disability is directly related to service. As for the Veteran's contention that the genitourinary disorder is secondary to his service-connected bilateral knee disabilities, the September 2010 VA examiner provided a probative and credible opinion against the claim that was based on a review of the claims file, examination of the Veteran, and established medical principles. The Veteran has submitted no medical evidence to the contrary. Since a preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply and the claim is denied. ORDER Service connection for a genitourinary disability, including as secondary to service-connected bilateral knee disabilities is denied. ____________________________________________ VITO A. CLEMENTI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs