Citation Nr: 1318210 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 10-25 472 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for residuals of an injury to the right testicle. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and O.F. ATTORNEY FOR THE BOARD Michael Holincheck, Counsel INTRODUCTION The Veteran served on active duty from May 1965 to August 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Veteran testified at a video conference hearing in June 2012 before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims folder. FINDINGS OF FACT 1. The Veteran suffered an injury to the right testicle in service in March 1966. He was hospitalized for treatment and diagnosed with acute epididymitis that was said to be unrelated to the trauma. 2. The evidence of record does not support a nexus between the Veteran's current symptoms and findings testicular pain and epididymal cysts and his right testicle injury in service. CONCLUSION OF LAW A disability of residuals of injury to the right testicle was not incurred in or aggravated during service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp 2013), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. Notice should also explain how VA assigns effective dates for benefits. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). Insufficiency in the timing or content of VCAA notice is harmless, however, if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). The Veteran submitted his claim for service connection in May 2007. The RO wrote to the Veteran in July 2007. He was provided with notice on how to substantiate his claim. He was further advised of the information required from him to enable VA to obtain evidence on his behalf, the assistance that VA would provide to obtain evidence on his behalf, and that he should submit such evidence or provide VA with the information necessary for VA to obtain such evidence on his behalf. The RO informed the Veteran on the types of evidence he could submit that would support his claim for service connection. He was asked to submit any medical evidence that he had. He was also afforded the notice required in Dingess. The Veteran responded to the letter in August 2007. He said he had no further information or evidence to submit. His claim was initially denied in December 2007. The Veteran submitted additional evidence to support his claim in June 2008. His claim was reconsidered but again denied in October 2008. The Veteran submitted his notice of disagreement (NOD) in February 2009. The Veteran was issued a statement of the case in May 2010 and perfected his appeal that same month. The Veteran has not disputed the contents of the VCAA notice in this case. He was afforded a meaningful opportunity to participate in the development of his claim. He was provided the necessary information on how to substantiate his claim for service connection and given examples of the types of evidence that would be beneficial in that endeavor. He was asked to submit evidence or identify evidence that the RO could obtain on his behalf. The Veteran submitted evidence in support of his claim, authorized VA to obtain private medical records, and submitted treatise material as additional support for his claim. Thus, the Board is satisfied that the duty to notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied. The Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate his claims. All available evidence pertaining to the Veteran's claim has been obtained. His service treatment records (STRs) were obtained and associated with the claims folder. VA records were submitted by the Veteran. Private treatment records were obtained and associated with the claims folder. The Veteran was afforded a comprehensive examination in April 2009. The Board finds that the examination was adequate to allow proper adjudication of the issue on appeal. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). The examiner conducted a complete examination, recorded all findings considered relevant under the applicable law and regulations, and offered a well supported opinion based on consideration of the full history of the disability. The Veteran testified at a Travel Board hearing in June 2012. At the hearing the Veterans Law Judge identified the issue on appeal. The elements necessary to establish service connection were clearly set forth. The Veteran and O.F. testified as to his continued symptoms. The Veteran and his representative presented argument as to how their treatise material supported a finding that the current disability was related to a right testicle injury in service as well as the epididymitis treated in service. The Board finds that the Veterans Law Judge provided the Veteran with a discussion of the issue on appeal and the evidence necessary to establish service connection and the evidence of record. See Bryant v. Shinseki, 23 Vet. App. 488 (2010); 38 C.F.R. § 3.103(c) (2012). The Board finds that VA has complied, to the extent required, with the duty-to-assist requirements found at 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c)-(e). I. Background The Veteran served on active duty from May 1965 to August 1967. He submitted his initial claim for VA disability compensation benefits, specifically for the issue on appeal, in May 2007. The Veteran contends that the current pain he is experiencing in his right testicle has existed off and on since an injury he sustained to his right testicle in service. The Veteran's service treatment records (STRs) show that in March 1966 he reported to sick call with a complaint of being struck in the right testicle by an air hose. The injury had occurred approximately 10 days earlier but the Veteran now had swelling and tenderness. The right testicle was noted to be swollen on examination. The assessment was epididymitis. The Veteran was admitted for further treatment the next day. He was hospitalized for 11 days. His discharge summary noted the initial injury. The Veteran's right testis was said to be normal with an enlarged epididymis that was twice the normal size and tender. The Veteran was placed on bed rest, with scrotal elevation and ice and given Achromycin. The summary said that, although the Veteran was admitted as an orchitis, secondary to trauma, it was felt that his condition was most likely epididymitis and most likely secondary to a low grade prostatitis. The physician said this was because of the pyuria manifested on urinalysis. Only the epididymis was involved and not the testis. The conclusion was that this represented a frank case of epididymitis with the trauma only as an incidental factor. The final diagnosis was epididymitis NEC (not elsewhere classified), acute, right. There are no further treatment entries relating to complaints of testicular pain or other episodes of epididymitis during the Veteran's remaining service. The Veteran did not report any problems with his testicles on his Report of Medical History completed as part of his separation physical examination in June 1967. His testes were specifically noted as normal on his separation physical examination. The Veteran identified only one source of post-service treatment in regard to his claim in May 2007. He identified having received treatment from the Louisiana State University (LSU) medical center from June 2000 to the then present. Records from the LSU medical center, for the period from June 2000 to May 2005, were received from that facility. The Veteran was seen in June 2000 with a complaint of a right testicular "knot." The Veteran reported a history of being injured in the service in the 1960s. The examiner said there was an 8-millimeter (mm) firm nodule in the right testis. The right testicle was nontender. The examiner said there was bilateral inguinal weakness. The impression/diagnosis was mild right epididymitis. The Veteran was seen in May 2005 for complaints associated with a recent weight loss. The entry noted a complaint of intermittent right testicle pain and a history of trauma to the area. The physical examination noted that there were no urinary symptoms. The testes were descended without masses. There was no inguinal hernia. There were no further complaints regarding the testicles or right epididymis in the LSU records. The Veteran's claim was initially denied in December 2007. He submitted a copy of a VA outpatient treatment record dated in April 2008. The entry noted the Veteran was last seen in April 2007. In April 2007, the Veteran reported that he experienced intermittent recurring testicular pain. He said he felt a mild degree of testicular pressure or discomfort all of the time. He reported having monthly episodes where he would sit in a tub of hot water for relief. As to his current visit he related a history of his testicles being contused by an air hammer in service [sic]. He said he had experienced moderate to severe testicular pain since that time. He said it mostly occurred during the summer. The entry also provided a lengthy review of the Veteran's complaints of low back pain. A past surgical history of right inguinal hernia repair was noted. No specific findings were reported for the testicles on physical examination. The impression was chronic testicular pain. The Veteran's claim for service connection was again denied in October 2008. The Veteran submitted his NOD in February 2009. He also submitted another VA primary care outpatient clinic note in support of his claim. The note was dated in January 2009 with summaries of outpatient visits by the Veteran in April 2007, April 2008, and October 2008. The April 2007 and 2008 information is noted above. The October 2008 visit related to the Veteran's low back pain. The current entry noted the Veteran complained of testicular/scrotal pain and lower back pain. It was said that the Veteran experienced chronic testicular pain due to an accident in service when an air hammer struck the Veteran in the scrotum. On physical examination the examiner said the Veteran's right testicle was tender and was almost one-third larger than the left testicle. The impression was chronic testicular pain since the military related to air hammer injury. The Veteran was afforded a VA examination in April 2009. The examiner noted that she had reviewed the Veteran's VA treatment records and the claims folder. She noted the Veteran's history of hernia repair, listed as occurring in 2000. The Veteran was noted as single but living with his companion of over 30 years. The examiner noted the Veteran's period of service and his specialty as an engine mechanic. The Veteran reported that he had worked in a factory until retirement two years earlier. He was in receipt of age-related Social Security retirement benefits. The Veteran described how he was hit in the right testicle by an air hose while in service. He said he had been having testicular complications since that injury. The examiner referenced the narrative summary contained in the STRs. She related the history of injury and treatment provided as stated in the summary. She noted that the Veteran was diagnosed with epididymitis secondary to low-grade prostatitis based on the pyuria found on urinalysis. She also noted the summary's conclusion that the Veteran's illness involved epididymitis with the trauma as only an incidental factor. The examiner also said that the Veteran's separation physical examination was negative for evidence of complaints of testicular pain or complications. The examiner said that the Veteran denied urinary frequency, nocturia, hesitancy of stream, and dysuria. He also did not have to void frequently through the night or during the daytime. The Veteran said he had experienced a brownish discharge since his injury. Past testing for sexually transmitted diseases was said to be negative. The Veteran reported that his right testicle never returned to its "normal" size after the injury. His said his right testicle remained swollen and his symptoms had progressed as he aged. The Veteran denied any urinary or bladder infections. He took Lortab for his pain but this was initially prescribed for his low back pain. The examiner noted that the Veteran said his testes were not examined on his discharge from service; however, the Board notes that the military examination report clearly stated that the Veteran's testes were examined and found to be normal. The examiner said that she found a small, approximately 6-mm mass or nodule on the posterior region of the right testicle. She said the right testicle was slightly enlarged. She said there was pain noted with palpation and examination of the right testicle as evidenced by facial grimacing and moans. There was no penile discharge noted and no testicular atrophy, bilaterally. An ultrasound was performed which found the following: The right testicle is normal in size measuring 4.7-centimeters (cm) x 2.0-cm. At the upper pole a simple cyst measuring 0.3-cm is noted. No abnormal vascularity. At the epididymis a large simple cyst measuring 4.3-cm x 2.5-cm. There is no internal echo shadowing and therefore suggests that this is simple cyst rather than spermatocele. The surrounding structure demonstrates some normal venous channel from the epididymis. On the left side the testicle measures 4.2-cm x 2.0-cm. It has a simple cyst measuring 0.7-cm x 0.5-cm at the mid-posterior aspect. There is also a smaller epididymal cyst measuring 1.5-cm x 0.8-cm. Impression: large simple epididymal cyst on the right. Benign small intratesticular cysts are not at both sides. Ultrasound report included in VA examination report of April 2009. The examiner provided diagnoses of epididymal cysts via ultrasound. She stated that there was no relationship to the history of epididymitis from right testicular trauma in 1966. She provided additional diagnoses of epididymitis, 1966, post right testicular trauma, resolved, and prostatitis, 1966, resolved. The examiner opined that the Veteran's epididymitis was not at least as likely as not due to his injury to the right testicle in service. In support of her opinion the examiner stated that genitourinary injury seldom posed a threat to life but mechanisms of injury are direct blows to the external genitalia is one. She said that blunt scrotal trauma may result in superficial ecchymosis and swelling or testicular rupture, torsion or displacements. The examiner said that testicular displacement occurred when the testicle is forced from the scrotum, usually into the peritoneal cavity. She cited to a specific medical reference in support of this statement. The examiner stated that the Veteran's right testicle was never displaced and remained in his scrotal sac even after his injury. The examiner noted the results of the ultrasound that found the 8-mm mass in June 2000. Finally, she stated that the Veteran did not have any documented chronic condition nor residuals due to his right testicular trauma. The Veteran's claim remained denied. His representative submitted additional argument in support of the claim in July 2010. The argument was that the Veteran had a chronic condition in service that had continued throughout the succeeding years. The representative stated that scientific literature indicated the debilitating signs and symptoms are recurrent by the nature of the impairment. It was further argued that the evidence showed that the Veteran was diagnosed with epididymitis in service as a direct result of his right testicle injury. Further, it was argued that the Veteran was unable to return to work for two months due to the condition. The representative said this was two weeks longer than the Merck Manual said was the threshold for epididymitis to become chronic. The representative also noted that the examination of April 2009 was performed by a nurse practioner rather than a medical doctor specialist. No specific argument or challenge was made as to the nurse practioner's qualifications; there was only an implicit argument that a medical doctor specialist's opinion should have been obtained. The Veteran and O.F. testified at a video conference hearing in June 2012. The Veteran began his testimony by relating how he was injured in service in 1966. He confirmed that he was diagnosed with epididymitis at that time. The Veteran was asked if he had had chronic and continuous symptoms since that time and he said that he had. He thought he experienced his symptoms two or three times a week, sometimes less often. He described his symptoms as chronic tenderness, redness and swelling. He said he had a cyst in the right testicle about in the same place where he was struck in service. He felt his condition had gotten progressively worse over the years. The Veteran's representative again citied to information in the Merck Manual as to how to define a chronic condition and that cysts can be a very common sign and symptom for the Veteran's condition. The Veteran said he sought treatment for his symptoms after service. He said he had tried to get the records but could not get in touch with most of the doctors that he saw. He could not remember their names. He said he was also told that most private doctors did not keep records after 15 years. O.F. testified that she had lived with the Veteran for about 40 years. She recalled the Veteran complaining about his right testicular pain a lot over the years. He would sit in hot water to relieve his pain. She said he told her how he was injured in service. The Veteran submitted copies of the treatise material he referenced in his hearing and in the earlier statement by his representative that were received in June 2012. The material consisted of a page from Dorland's Illustrated Medical Dictionary, 31st edition, that had definitions for epididymal, epididymis, and epididymitis circled. The second submission was an excerpt from the Merck Manual, 17th edition, that was an entry regarding epididymitis. In addition, the submission included information regarding a one page discussion of prostatitis from an unknown source and a one page discussion of epididymitis and orchitis from American Family Physician. No medical opinion accompanied the treatise material. The Board sought a Veterans Health Administration (VHA) opinion in this case in January 2013. The opinion was received in February 2013. The Veteran was provided with a copy of the opinion and given the opportunity to submit additional evidence and/or argument in light of the opinion. The opinion was provided by a VA physician that is the head of a urology section at a VA medical center. The examiner said he had reviewed the claims folder. He stated that it was at least as likely as not that the Veteran's complaints were not related to his history of trauma to the right testicle in 1966. The examiner noted that records from March 1966 stated the Veteran suffered trauma to the testicle with associated pain which resolved within 24 hours. Four days later the Veteran developed pain and swelling of the right testicle. Five days after the onset of the swelling, or 10 days post trauma, he presented to the hospital with progressive swelling/tenderness of his right testicle/epididymis. A urinalysis revealed findings consistent with a urinary tract infection. The Veteran was diagnosed with prostatitis and secondary epididymitis with the trauma felt to be "incidental to the development of his symptoms". The examiner said the Veteran was felt to not have a major testicular injury and on discharge from the hospital he was doing well without pain and a marked reduction in his swelling had occurred. The examiner stated that epididymitis can have multiple etiologies, i.e. idiopathic, related to a known urinary tract infection and trauma. He said most cases are idiopathic. In the Veteran's case the epididymitis was felt to be secondary to his urinary tract infection. He said that, in addition, if it had been due to the trauma he would have expected his symptoms to have started prior to 5 days following the trauma. The examiner stated that there is no reason to think the urinary tract infection and "prostatitis" could be related to the air hose trauma, i.e. the trauma to the scrotum would not cause a urinary tract infection or prostatitis. He noted that the Veteran's June 1967 separation physical examination noted the Veteran's testicles as normal. The examiner also discussed the treatment entries from the LSU facility. He noted that the Veteran did not complain of testicular pain when seen in June 2000. Rather, the Veteran said he had a "knot" in the right testicle. The physical examination revealed an 8-mm "tender knot at the superior pole of the testicle." The examiner said the written report of an ultrasound noted only an epididymal cyst on the left. He said he was not sure if they meant the right nor not and there was no official reading of the ultrasound. He said he did not think this was critical to making a determination in this case. No treatment was given or felt to be indicated. He said the presence of such a cyst is very common on both physical exams and testicular ultrasounds without any history of trauma. He noted the Veteran was seen in May 2005 and there was no mention of any testicular pain and no testicular abnormalities were noted on physical examination. The examiner noted the April 2007 VA entry where the Veteran mentioned intermittent testicular pain; however, no examination was reported. He also referenced the April 2008 entry and the Veteran's report of self-treatment for his testicular pain. In particular, the examiner noted the Veteran said he felt as if he had two testicles on one side. The examiner stated that the "second" testicle could well be related to the large epididymal cyst that was identified on ultrasound. He said the entry did not mention a physical examination of the testicles. The examiner referenced the results of the January 2009 outpatient visit. At that time the Veteran's right testicle was said to be one-third larger than the left. He further noted that an ultrasound done in April 2009 revealed what he said was a simple right epididymal cyst that was measured as 4.3-cm x 2.5-cm and a smaller 3-mm upper pole right testicular cyst that the examiner said was likely of no significance. He said that, typically, such epididymal cysts were asymptomatic except for discomfort caused by their size. In this case, the cyst was about the size of the Veteran's testicle. The examiner stated that he was unable to relate the development of the cyst to the trauma some 43 years earlier as such cysts are actually quite common without any history of trauma. The examiner said that, whether the large epididymal cyst represented growth of the cyst noted in 2000 is unknown but could well be. He also said that it may be true that an epididymal cyst can be associated with epididymitis. However, whether one is the cause of the other is certainly open to debate as both occur separately in patients and there is no reason to think that some patients may not have both. Finally, he noted that, according to the medical records, the Veteran had not had a urinary infection other than in 1966. The Veteran's representative submitted additional written argument that was added to the claims folder in April 2013. II. Analysis The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Board notes that 38 C.F.R. § 3.303(b) does provide for consideration of service connection based on a continuity of symptoms. However, this is based on a finding of a chronic disease being shown in service. The United States Court of Appeals for the Federal Circuit has held that the purpose of 38 C.F.R. § 3.303(b) is "to afford an alternative route to service connection for specific chronic diseases" that are listed in 38 C.F.R. § 3.309(a) (2012). See Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013). Epididymitis, epididymal cysts and testicular pain are not listed as chronic diseases for consideration of 38 C.F.R. § 3.303(b). Generally, service connection requires (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999); accord Caluza v. Brown, 7 Vet. App. 498 (1995). In this case, the STRs document an incident of trauma to the right testicle in service when the Veteran was struck by an air hose. He was not hit in the scrotum by an air hammer as erroneously recorded in the VA treatment records. However, the STRs do not show any residuals from that trauma. The Veteran was treated for epididymitis that was found to be related to prostatitis. The pertinent discharge summary stated that the trauma to the right testicle was only incidental. Although the Veteran has stated that he suffered from continued right testicle pain since the trauma, there are no additional STR entries showing treatment. His epididymitis was resolved at the time of his discharge from the hospital in April 1966. No cysts were identified in service. His June 1967 separation examination is negative for any abnormalities and the testes are specifically noted as normal. Further, the Veteran did not report any problems with his testicles on his medical history in June 1967. See Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011)(where there is a lack of notation of medical condition or symptoms where such notation would normally be expected, the Board may consider this as evidence that the condition or symptoms did not exist). The earliest medical evidence of record that documents a complaint of right testicular pain after service is from the LSU record entry of June 2000. At that time the Veteran gave an accurate history of trauma to the right testicle in service in the 1960s. He did not report recurrent or continuous symptoms. He was diagnosed with an 8-mm nodule on the superior pole of the testicle. Based on the LSU records, he was not seen again for a complaint related to his right testicle. The Veteran was seen at a VA facility in April 2007. He reported intermittent testicular pain. In April 2008 he gave a history of being hit in the scrotum with an air hammer and suffering contused testicles in service. He reported having continued pain since that time. It is of note that a past surgical history of right inguinal hernia repair was noted in the VA entry. The Veteran did not identify this treatment to VA and did not submit or authorize VA to obtain records associated with this surgery. It appears this surgery occurred sometime between June 2000, when the LSU entry said that both inguinal rings appeared weak, and the April 2008 VA entry when the surgery was noted. No prior surgery was reported in the June 2000 and May 2005 LSU entries. The VA entry from January 2009 included a note from October 2008. Both entries noted continued testicular pain. The VA physician related the pain to the air hammer injury in service. However, there is no physical examination of the testicles reported and no specific findings made. There is only the assessment of chronic testicular pain. Moreover, the examiner had no access to the Veteran's STRs to assess the actual incident in service and the epididymitis that was related to an infection instead of trauma. The April 2009 VA examiner reviewed the STRs and other evidence of record. She also provided her own physical examination findings and included the results of a concurrent ultrasound. The examiner further found that the epididymitis and prostatitis noted in service were resolved in 1966. She stated that there was no relationship between the Veteran's trauma in service and his finding of epididymal cysts. The VHA medical opinion also found no relationship between the trauma to the right testicle in service and the Veteran's current complaints of pain in the right testicle and his diagnosed epididymal cysts. The examiner said that if the Veteran's epididymitis in service had been due to trauma, he felt the Veteran would have had symptoms prior to five days after the trauma. The examiner concurred that the epididymitis in service was due to the diagnosed infection and not trauma. The examiner also reviewed the post-service medical evidence. This includes the finding of the tender 8-mm knot in June 2000 as well as the cysts discovered on the VA ultrasound of April 2009. The examiner said such cysts are usually asymptomatic except for discomfort that may be related to their size. The examiner stated he could not relate the development of the cysts to the trauma suffered in service, some 43 years earlier, as such cysts were actually quite common without any history of trauma. The examiner also addressed the Veteran's argument that epididymitis and the epididymal cysts were related by saying that may be true. He said that, whether one is the cause of the other was open to debate as both occur separately in patients and there was no reason not to think that some patients may have both. The Board notes the Veteran's contentions of having continued pain in the right testicle since his injury in service. The Board also has considered the testimony of O.F. of observing the Veteran's symptoms. The Veteran is competent to report his symptoms of pain and swelling and self-treatment. See Barr, 21 Vet. App. at 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus). He is not competent to relate such symptoms as being related to his trauma to the right testicle in service. Further, he is not competent to say he had chronic epididymitis in service that has resulted in his development of epididymal cysts during the pendency of his appeal. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau, 492 F.3d 1377 at n.4 (Fed. Cir. 2007) ("Sometimes 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."). In addition, unlike the case in Buchanan v Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), there are contemporaneous STR entries that note treatment for a specific injury in service but also include a finding that then treated epididymitis was unrelated to the injury and that the epididymitis was acute and resolved. Further, a contemporaneous STR entry, by way of physical examination in 1967, specifically noted the Veteran's testes as normal. The Veteran has also argued that he was unable to return to duty for two months due to his epididymitis in service and that, according to his treatise information, this constituted chronic epididymitis as opposed to acute. This argument is without merit. The Veteran was hospitalized for a total of 11 days. His infection was resolved at the time of his discharge from the hospital and he was immediately returned to duty. It is not clear what evidence the Veteran believes supports his contention in this regard. It is clear that his STR entries unequivocally show his discharge to duty after his brief period of hospitalization. The Board understands the Veteran's argument that he believes his epididymitis in service is related to his current right testicle pain and development of epididymal cysts. He has relied on the several treatise entries as support for this argument. However, the material submitted by the Veteran is general in nature. It discusses possible connections. He has not submitted any medical evidence that supports his interpretation and application of the treatise material. See Sacks v. West, 11 Vet. App. 314 (1998). Moreover, there is medical evidence, by way of the April 2009 VA examination report and February 2013 VHA medical opinion, that specifically hold that the claimed relationship does not exist in this case. Upon review of the evidence of record, the Board finds that the objective medical evidence of record does not establish a link between the Veteran's diagnosed right testicular pain and epididymal cysts and his military service. Further, the medical opinion evidence of record is considered to be more probative in this case as the Veteran's military records, post-service medical records and contentions have been considered but the determination still made that there is no relationship to service, to include the trauma to the right testicle. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Therefore, the Board is unable to identify a reasonable basis for granting service connection in this case and the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). ORDER Entitlement to service connection for right, acute epididymitis with testicular pain is denied ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs