Citation Nr: 1321329 Decision Date: 07/02/13 Archive Date: 07/12/13 DOCKET NO. 07-11 972 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected diabetes mellitus. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. T. Sprague, Counsel INTRODUCTION The Veteran had active service in the United States Army from October 1967 to June 1988, to include duty in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The claim has been before the Board on two previous occasions, and was remanded in April 2010 and December 2012 for evidentiary and remedial development purposes. In the course of the appeal, a claim for entitlement to service connection for diabetes mellitus was granted by the Appeals Management Center (AMC) in May 2013. The claim is ripe for appellate review. The Veteran's physical claims file, to include the portion contained in the electronic Virtual VA system, has been reviewed. FINDING OF FACT The Veteran's usage of Metformin(r) to treat service-connected diabetes has played a causal role in the development of erectile dysfunction (ED). CONCLUSION OF LAW The criteria for entitlement to service connection for erectile dysfunction have been met. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Applicable law provides that service connection will be granted if it is shown that the Veteran experiences a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a preexisting injury or disease contracted in the line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service alone is not enough; there must be chronic disability resulting from that injury. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998) (citing Cuevas v. Principi, 3 Vet. App. 542, 548 (1992)). Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran in this case was recently granted service-connected compensation benefits for his type II diabetes mellitus. The Veteran served in Vietnam, and the disorder was granted based on a presumed exposure to herbicides in that country. He contends, in essence, that erectile dysfunction (ED) was caused or aggravated beyond the disease process by his now service-connected diabetes. The Veteran has had ED for many years, with Army department treatment records documenting a male erectile disorder at least as early as 2004 (Veteran is a military retiree). At that time, while diabetes was not diagnosed, the Veteran had a noted metabolic abnormality. Treatment for the symptoms associated with what would eventually become diabetes began in approximately 2005, and the Veteran has consistently been on Metformin(r) since that time. In December 2006, the Veteran was first offered a VA examination to assess whether he experienced diabetes. An addendum opinion was entered following this assessment which stated that diabetes was not yet present at that time; however, the Veteran had abnormal fasting glucose problems, and as noted, was taking medication to control his blood sugar problems. With regard to ED, it was specifically noted that the disorder occurred, and with respect to etiology, the examiner noted that there were "genitourinary symptoms relat[ed] to diabetes" present at the time of examination. Further discussion noted that ED was specifically present, and that "medication" was the most likely etiology of his ED. The examiner stated that "since the Veteran does not have diabetes at this time, ED is not secondary to diabetes." As the medication responsible for the onset of ED was specifically discussed as "relating to diabetes," the Board can assume that the examiner's opinion was that the usage of medicine to treat diabetic symptoms (which had not, at that time, developed into full diabetes) played a causal role in the onset of ED. Indeed, it was only the lack of a formal diagnosis of diabetes at that time of the 2006 examination which prevented the examiner from linking the two conditions; however, by opining that diabetic medication played a role in the onset of diabetes, it is reasonable to conclude that should the disability eventually manifest, the medication used to treat such a disability (if still being utilized) would still contribute to ED. The Veteran was examined on two further occasions, and the June 2010 examination report noted that Metformin(r) was still being used. The Veteran was not noted to have diabetes at that time. In April 2013, the Veteran was examined yet again, and type II diabetes was assessed. Metformin(r) was still being taken at the same dosage level present in 2006. The examiner opined that the Veteran's ED pre-existed his diagnosis of diabetes, and that he did not display evidence of microvascular issues or neuropathy which would be productive of diabetes-related ED. No discussion was made with respect to the impact continuing treatment with Metformin(r) would have regarding the onset of diabetes; however, the examiner did note that "certain medications" can have an impact on blood flow, and while it appears as if the examiner was potentially limiting his discussion to treatment for nonservice-connected blood pressure problems, he did not rule out any medication used to treat diabetes (which, as noted, the Veteran has been taking for many years, and which the examiner noted was still prescribed in 2013). Essentially, while the evidence with regard to the contribution of diabetes to ED on a direct basis is not supportive, there has been a consistent reporting of ED as being attributable, at least in part, to his treatment for diabetic symptoms, and later, to his diagnosed diabetes. Indeed, the 2006 examiner specifically related ED to treatment for a pre-diabetes glucose abnormality, and the only prescribed medication for that condition was Metformin(r). Essentially, the examiner noted that but for a diagnosis of diabetes, there would be a relationship between ED and that condition (as due to the prescription of Metformin(r)), and the 2013 examiner did not exclude the Veteran's diabetic medication as one of a "certain" type which are potentially causative of ED due to impact on blood flow. The Veteran's drug regimen has not changed since 2006, with the only development since that time being that, as of the 2013 VA examination report, the Veteran has a clear diagnosis of diabetes mellitus. The Veteran's diabetes has been service-connected, and the treatment prescribed is the usage of Metformin(r). Indeed, whether used to treat pre-diabetic symptoms or outright diabetes, this medication has been specifically linked by a physician to ED, and while not directly referenced, it has not been excluded as a medication that can limit blood flow and hence have an impact on erectile power. There is nothing of record to controvert these findings, and they are fully supportive of the Veteran's assertions. Indeed, as the Veteran now has service-connected diabetes, and as his Metformin(r) usage is the only treatment for that service-connected disability which has, uncontrovertibly, been linked by a competent medical authority to ED, the requirements for service connection have been met. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Accordingly, the claim is granted. ORDER Entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected diabetes mellitus, is granted. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs