Citation Nr: 1322846 Decision Date: 07/17/13 Archive Date: 07/24/13 DOCKET NO. 07-19 355 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for hypertension, including as secondary to service-connected Diabetes Mellitus Type II. 2. Entitlement to service connection for erectile dysfunction, including as secondary to service-connected Diabetes Mellitus Type II. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A.E.H. Gibson, Associate Counsel INTRODUCTION The Veteran had active duty service from December 1965 to September 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which, in pertinent part, denied service connection for hypertension and erectile dysfunction. The Veteran timely appealed these issues. In September 2010, the Veteran testified at a Travel Board hearing that was chaired by the undersigned Acting Veterans Law Judge (AVLJ). A transcript of the hearing has been associated with the Veteran's VA claims file. This matter was before the Board in July 2011 and December 2012. Each time, the Board remanded the claims for additional development, including the provision of VA examinations. In February 2013, the Veteran contacted the Board, requesting clarification of a statement found in the Board's December 2012 remand. In the body of the remand, the Board indicated that the Veteran had been awarded service-connection for a left varicocele, which had been originally rated as 10 percent disabling but then raised to 20 percent disabling, effective June 13, 2008. The Veteran had not been notified of the increase and wanted more information. Upon review, it is clear that this statement was made in error, and the Board meant to indicate that his service-connected Diabetes Mellitus Type II was assigned a 20 percent rating effective June 13, 2008. The Veteran's service-connected left varicocele is still rated as 10 percent disabling. The Board apologizes for the error, and any confusion caused. Review of the Virtual VA paperless claims processing system does not reveal additional documents pertinent to this appeal. FINDINGS OF FACT 1. The Veteran's hypertension did not have its onset in active duty service, and is not otherwise related to active duty service, including as due to service-connected Diabetes Mellitus Type II. 2. The Veteran's erectile dysfunction did not have its onset in active duty service, and is not otherwise related to active duty service, including as due to service-connected Diabetes Mellitus Type II. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. The criteria for entitlement to service connection for erectile dysfunction have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104 (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each piece of evidence. See Gonzales, 218 F.3d at 1380-81. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. Id. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Id. Veterans Claim Assistance Act (VCAA) The Veterans Claims Assistance Act (VCAA) provides that VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of what is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012). The VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and, (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). All notice under the VCAA should be provided prior to an initial decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). However, the issuance of a fully compliant VCAA notification followed by readjudication of the claim is sufficient to cure a timing defect. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006), the United States Court of Appeals for Veterans Claims (Court) observed that a claim of entitlement to service connection consists of five elements: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and, (5) effective date. See 38 U.S.C. § 5103(a) (West 2002 & Supp. 2012). Compliance with the first Quartuccio element requires notice of these five elements. See id., at 486. The duty to notify has been satisfied. VCAA notice was sent to the Veteran in March 2006 and August 2006, which also contained the notifications required by Dingess. The VCAA further provides that VA has a duty to assist the veteran in the development of the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). This duty includes assisting him in obtaining service treatment records (STRs) and other pertinent treatment records, as well as providing an examination or obtaining a medical opinion when such is necessary to make a decision on the claim. See id. The duty to assist has also been satisfied. The Veteran's STRs and post-service medical records have been associated with the file. The Veteran has been afforded VA examinations for hypertension and erectile dysfunction in July 2007, September 2011, and February 2013, and the reports are included in the file. The Board finds the February 2013 examination report adequate to adjudicate the Veteran's claims, as the examiner rendered them with background knowledge of the Veteran's medical history, and fully supported his opinions with explanatory rationale. Further, the examination report directly addresses the issues under consideration. In regard to the July 2011 and December 2012 remands, the Board finds that there has been substantial compliance with the remand directives, which included obtaining records, scheduling VA examinations, and obtaining addendum medical opinions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran was afforded a hearing before an AVLJ in September 2010, during which he presented oral argument in support of his claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the hearing officer who chairs a hearing (1) fully explain the issue, and (2) suggest the submission of evidence that may have been overlooked. Here, the parties agreed the issues under appeal were service connection for hypertension and erectile dysfunction, both including as due to his service-connected diabetes. The Veteran presented testimony as to why he thought his current diagnoses were related to service, and indicated his private physician had made a positive nexus, which is located in the file. Thus it was clear that the Veteran and his representative understood what was needed to substantiate his claim. Additional evidence was not suggested, however, the Veteran was provided with VA examinations to obtain nexus opinions. To that end, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the hearings. Accordingly, the Board finds that, consistent with Bryant, the AVLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Service connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty service. 38 U.S.C.A. §§ 1110, 1131. Service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the Federal Circuit held that a three-element test must be satisfied in order to establish entitlement to service connection. Walker v. Shinseki, 708 F.3d 1331, 1333 (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Id. Certain diseases are considered chronic, per se, and therefore will be presumed to have been incurred in service if manifested to a compensable degree (generally meaning to at least 10-percent disabling) within one year following separation from service. This presumption, however, is rebuttable by affirmative evidence to the contrary, and only applies to the disabilities listed in 38 C.F.R. § 3.309(a). 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). Claims to service connect the chronic diseases listed in 38 C.F.R. § 3.309(a) may also benefit from a somewhat more relaxed evidentiary standard under 38 C.F.R. § 3.303(b). See Walker, 708 F.3d at 1339 (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases"). Specifically, when a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain in a claim for arthritis or abnormal heart action in a claim for heart disease) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. The Federal Circuit noted that the requirement of showing a continuity of symptomatology after service under subsection 3.303(b) is a distinct and lesser evidentiary burden than the nexus element of the three-part test discussed above: "The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" (emphasis added). Walker, 708 F.3d at 1338-1339. Thus, showing a continuity of symptomatology after service is an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation." Id. at 1338; see also id. at 1336 (observing that section 3.303(b) provides a "second route by which a veteran can establish service connection for a chronic disease"). A continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. at 1338. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the more relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. Thus, if the claimed disability is not one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and "the 'nexus' requirement of the three-element test" must be satisfied in order to establish entitlement to service connection benefits. Id. Because one of the Veteran's claims is for hypertension, which is included among the chronic diseases in section 3.309(a), the provisions of subsection 3.303(b) for chronic disabilities apply, and the claim may be supported by evidence of a continuity of symptomatology after service. See Walker, 708 F.3d at 1338-1339. The Veteran's erectile dysfunction is not listed under section 3.309(a), thus service connection for that disability cannot be established under the presumption contained in sections 3.303(b). VA regulations also provide that certain diseases associated with exposure to herbicide agents, including Agent Orange, may be presumed to have been incurred in service even if there is no evidence of the disease in service, provided the requirements of 38 C.F.R. § 3.307(a)(6) are met. See 38 C.F.R. § 3.309(e) (2012). In order to benefit from the presumption of service connection for diseases associated with herbicide exposure, the veteran must have one of the diseases enumerated in 38 C.F.R § 3.309(e). The diseases presumed to be caused by herbicide exposure include AL amyloidosis, chloracne or other acneform disease consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft- tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). Neither hypertension nor erectile dysfunction are among the listed diseases. Under the authority granted by Congress in the Agent Orange Act of 1991 and the Veterans Education and Benefits Expansion Act of 2001, the Secretary has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See 72 Fed. Reg. 32395, 32397-32398 (June 12, 2007). Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and, (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). At the Veteran's induction examination in December 1965, his genitourinary and vascular systems were clinically evaluated as normal. His blood pressure was 138/84. At his separation examination in September 1967, his genitourinary and vascular systems were again clinically evaluated as normal. His blood pressure was 138/86. During the examination, the Veteran did not note a history of high blood pressure or genitourinary trouble. In August 1978, the Veteran's BUN was 12 mg/dL and his creatinine was 1.1 mg/dL. On October 2004, the Veteran established care with a private urologist, Dr. K.L., for treatment of erectile dysfunction. He told the physician that he had been experiencing the symptoms constantly over the previous year. His blood pressure was 132/80, and the doctor found him to be in good health. His assessment was impotence of organic origin. Lab results from April 20, 2005, show BUN of 13.0 and creatinine of 1.1, both within the reference range provided with the results. Results from September 19, 2005, show BUN of 12 mg/dL, within the reference range of 5 to 26, and creatinine of 1.1 mg/dL, also within the range of 0.5 to 1.5. Lab results from January 30, 2006, show BUN of 17 mg/dL, within the range of 5 to 26, and creatinine of 1.3 mg/dL, within the range of 0.5 to 1.5. At an April 2006 appointment to establish care and manage hypertension, diabetes, and erectile dysfunction, the Veteran was found to have borderline diabetes. A urinalysis showed BUN of 15.0, and creatinine of 1.1, both within the reference range provided with the lab results. At the July 2007 VA examination for diabetes, it was noted the Veteran was not taking any medication to control his diabetes symptoms. His urea nitrogen (BUN) was 14 mg/dL, within the range of 6 to 20, and his creatinine was 1.1 mg/dL, within the range of 0.6 to 1.4. The VA examiner concluded that hypertension was diagnosed prior to his diabetes, and therefore not due to diabetes. He also opined that erectile dysfunction, which the Veteran indicated he had had for the last four years, was not due to diabetes because it incepted prior to diabetes. Lab results from August 13, 2008, show the Veteran's BUN as 15 mg/dL, and the reference range was noted to be between 5 and 26. His creatinine was 1.15 mg/dL, and the reference range was between 0.5 and 1.5. A September 28, 2009, letter from Dr. K.L. indicated he reviewed the Veteran's STRs. He noted the report of varicocele and penile pain in the past, and that the Veteran was currently taking medication for hypertension and diabetes. He also noted the Veteran was taking testosterone for hypogonadism. He said there are three factors that contribute to the Veteran's impotence, and they all work together to have an additive effect. He also thought that blood pressure medication contributed to impotency. Lab results from May 12, 2010, show creatinine of 1.1 and urea nitrogen (BUN) of 7. It was noted his hypertension was stable. On April 27, 2011, lab results show the Veteran's urea nitrogen (BUN) was 11 and his creatinine was 1.1. His results were noted to be normal, and it was also noted that BUN and creatinine measure kidney function. At the September 2011 VA examination, the examiner noted the Veteran's private physician, Dr. K.L., diagnosed hypogonadism and organic impotency, and said that the Veteran's blood pressure medication contributes to erectile dysfunction. The Veteran stated he had had erectile dysfunction since the 1980s. The VA examiner opined that erectile dysfunction was not due to diabetes, because it predated diabetes by several years. He opined that hypertension was not related to diabetes because there is no renal involvement. He elaborated that if there were renal involvement, then it would be related to diabetes. An October 2012 addendum opinion addressing Dr. K.L.'s September 2009 opinion agrees that blood pressure medication could cause erectile dysfunction. The examiner maintained his opinion that erectile dysfunction was not due to diabetes because it preceded diabetes. On February 5, 2013, the Veteran's creatinine was 1.0 mg/dL, within the reference range of 0.6 to 1.4. At the February 2013 VA examination for male reproductive system conditions, the Veteran reported having erectile dysfunction since the 1980s, and that it has worsened since that time. It was noted that he was diagnosed with hypertension in 2001 and diabetes in 2007. He was diagnosed with erectile dysfunction, and a left varicocele, for which the Veteran is already service-connected. The VA examiner opined that erectile dysfunction is not caused or aggravated by the Veteran's varicocele, as a varicocele is not a recognized risk factor for the development of erectile dysfunction. He rejected Dr. K.L.'s opinion that the varicocele contributed to impotence, noting that this is not supported by the medical literature. He listed the Veteran's conditions that are known risk factors for erectile dysfunction as age, diabetes mellitus, hypertension, dyslipidemia, and medication use. Obesity, cardiovascular disease, and smoking were also listed, but do not apply to the Veteran. The VA examiner noted that age is the most important etiologic factor for development of erectile dysfunction, and that a 66-year-old man has a greater than 60 percent chance of developing it. He opined that the Veteran's erectile dysfunction is likely attributable to a combination of his risk factors, and that it would not be possible to quantify the amount each factor contributed without resorting to speculation. He further noted that the Veteran's diabetes has been well-controlled with no complications, and because of that, thought the impact of the Veteran's diabetes on his erectile dysfunction was minimal to none. It was noted the claims file was not reviewed, however, the claims file was made available to the examiner and reviewed in April 2013, and no changes were made to the opinion. At the February 8, 2013, VA examination for hypertension, it was noted the Veteran's hypertension was diagnosed in or around 2001. The VA examiner opined that the Veteran's hypertension was not caused or aggravated by his diabetes because records show that his renal function is normal. He opined that the Veteran has essential or primary hypertension, which is the most common form of hypertension, affecting between 80 and 95 percent of hypertensive patients. He said that diabetes is not a risk factor for the development of hypertension. It was noted the claims file was not reviewed, however, the claims file was made available to the examiner and reviewed in April 2013, and no changes were made to his opinion. The Veteran has submitted testimony wherein he asserts that his hypertension is related to Agent Orange exposure, as well as his diabetes, and that his doctor has told him that it is related to diabetes. He also asserts that his diabetes has aggravated his erectile dysfunction, which he has experienced since the 1980s. It is undisputed that the Veteran has been diagnosed with hypertension and erectile dysfunction. The remaining inquiry is whether these disabilities are related to his period of active duty service. In regards to hypertension, the evidence indicates it was not diagnosed until 2001, over thirty years after the Veteran separated from service. Because it did not manifest to a compensable degree within one year after separation from service, and it was never noted in service, it cannot be service connected under the presumptions applicable to chronic conditions contained in 38 C.F.R. §§ 3.303(b) and 3.307. Hypertension is not among the diseases presumed to be associated with herbicide exposure, which are enumerated in 38 C.F.R. § 3.309(e). Thus, it cannot be service connected under the presumption applicable to veterans exposed to Agent Orange. The Veteran has alleged that his hypertension is secondary to his service-connected diabetes. The Veteran has not been shown to have medical training or expertise to competently make such an assertion, and the Board does not find this statement probative to the issue. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). Instead, the competent evidence of record indicates that the Veteran's hypertension is not related to his diabetes, as demonstrated by his normal kidney function. Indeed, the evidence of record shows that Veteran's creatinine and urea nitrogen (BUN), both of which are tests of kidney function, have always been within normal limits. Further, the February 2013 VA examiner noted that hypertension is not a complication of diabetes. See Flynn v. Brown, 6 Vet. App. 500, 506 (1994) (hypertension that is not the result of diabetes-induced renal disease, i.e., essential hypertension, is not found among the complications of diabetes mellitus). The Veteran has not alleged that hypertension is related to service in a different way, and there is no other competent evidence that the two disabilities are related. The Veteran's assertion that his physician has told him that his hypertension is related to his diabetes is not probative. The connection between what a physician said and the layman's account of what he purportedly said, filtered as it was through a layman's sensibilities, is simply too attenuated and inherently unreliable to constitute competent medical evidence. Robinette v. Brown, 8 Vet. App. 69, 77 (1995). As such, it is outweighed by the abundance of competent evidence showing that hypertension is not related to service. In regards to erectile dysfunction, it is not a "chronic" condition pursuant to 38 C.F.R. § 3.309(a), and cannot be service connected via the presumptions set forth in 38 C.F.R. §§ 3.303(b) and 3.307. The Veteran has alleged that he has experienced erectile dysfunction symptoms since the 1970s or 1980s. He has alleged that it is related to his diabetes, arguing that it has directly caused erectile dysfunction or has aggravated it. He has also alleged that his blood pressure medication aggravates it. As above, the Veteran has not been shown to have the medical training or expertise to competently diagnose the cause of his erectile dysfunction as due to, or aggravated by, diabetes. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). Accordingly, the Board does not find his statement probative to the issue. The Board does not find Dr. K.L.'s September 2009 opinion probative. Primarily, it is not clearly written, in that he lists five items from the Veteran's medical history (a varicocele, a history of penile pain, a hypertension diagnosis for which he takes medication, a diabetes diagnosis for which he takes medication, and a hypogonadism diagnosis for which he takes hormones), but then said that there are three factors that contribute to his impotence, which are likely to have an additive effect. He does not specify what factors he is referring to. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion comes from when there is factually accurate, fully articulated, and sound reasoning for the conclusion). He specifically noted that hypertension medication contributes to erectile dysfunction, but hypertension has not been service connected. The February 2013 VA male reproductive system conditions examination is the most probative evidence addressing the issue, as it clearly addresses the outstanding issues with clear explanations for the opinions provided. The Veteran is already service-connected for a varicocele and for diabetes, which Dr. K.L. appeared to be implicating in his opinion, and the examiner opined that these conditions were not causing or aggravating his erectile dysfunction. The examiner said that he knew of no relationship between a varicocele and erectile dysfunction, and he did not find any support for such a relationship in the medical literature. The February 2013 VA examiner also opined against the possibility that the Veteran's diabetes was causing or aggravating erectile dysfunction. He noted that the Veteran's age is his most likely risk factor for erectile dysfunction, but that diabetes, hypertension, dyslipidemia, and medication use are also all risk factors. He opined that, in the Veteran's case, they likely worked in combination with one another, and that it would not be possible to quantify the contribution of each factor. He did, however, note that the Veteran's diabetes has been kept under control, and he has had no complications. Because his diabetes has been so well cared for, he thought that its impact on erectile dysfunction was minimal to none. There is no other competent evidence that probatively outweighs the February 2013 VA examination reports. Accordingly, the preponderance of the evidence is against this claim, and under these circumstances the benefit-of-the-doubt rule does not apply. The Veteran's claims must be denied. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2011). See also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for erectile dysfunction is denied. ____________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs