Citation Nr: 1324474 Decision Date: 08/01/13 Archive Date: 08/13/13 DOCKET NO. 07-23 643 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to a service-connected disability. 2. Entitlement to service connection for erectile dysfunction, to include as secondary to a service-connected disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran served on active duty from February 1968 to August 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in May 2006 and August 2006 by the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. Subsequently, the Board remanded this matter for additional development in an April 2011 decision. The following determination is based on review of the Veteran's claims file in addition to his Virtual VA "eFolder." FINDINGS OF FACT 1. The evidence of record does not show that the Veteran's hypertension is etiologically related to his period of active service, or any incidents therein (to include presumptively), nor proximately due to, the result of or chronically aggravated by his service-connected posttraumatic stress disorder (PTSD) or any other service-connected disability or to the medications used to treat them. 2. The evidence of record does not show that the Veteran's erectile dysfunction is etiologically related to his period of active service, nor proximately due to, the result of or chronically aggravated by his service-connected PTSD or any other service-connected disability or to the medications used to treat them. CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated by active service, nor may service incurrence be presumed, and was not proximately due to, the result of, or chronically aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. Erectile dysfunction was not incurred in or aggravated by active service, and was not proximately due to, the result of, or chronically aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) and as interpreted by the United States Court of Appeals for Veterans Claims (the Court), have been satisfied by information provided to the Veteran in letters from the RO dated in December 2005 and March 2006. These letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claims, and identified the Veteran's duties in obtaining information and evidence to substantiate his claims. Thereafter, rating decisions were issued in May 2006, which denied the Veteran's claim for service connection for erectile dysfunction, and in August 2006, which denied the Veteran's claim for service connection for hypertension. (See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 20 Vet. App. 473 (2006); and Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006). At the time these claims were filed, the Court in Dingess/Hartman found that the VCAA notice requirements applied to all elements of a claim. An additional notice as to disability ratings and effective dates was provided in the March 2006 correspondence. In any event, the Veteran and his representative have not argued that any error or deficiency in the accomplishment of the duty to notify has prejudiced him in the adjudication of his appeal. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). In view of the above, the Board finds that the notice requirements pertinent to the issues on appeal have been met. The duty to assist also has been fulfilled as VA and private medical records relevant to these claims have been requested and obtained and the Veteran has been provided with VA examinations of the conditions on appeal, including a thorough and adequate examination and medical opinion in May 2011 as requested in the Board's April 2011 remand. Therefore, the Board finds that the RO/AMC has substantially complied with the Board's remand instructions on developing evidence. See D'Aries v. Peake, 22 Vet. App. 97, 106 (2008). The Board finds that the available medical evidence is sufficient for an adequate determination of these claims. There has been substantial compliance with all pertinent VA laws and regulations and to move forward with these claims would not cause any prejudice to the Veteran. Service Connection - Laws and Regulations Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in line of duty or for aggravation of preexisting injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303. VA regulations also provide that where a veteran served 90 days or more of continuous, active military service during a period of war or after January 1, 1947, and certain chronic diseases, including hypertension, become manifest to a degree of 10 percent within one year from date of termination of service, such disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Generally, in order to prevail on the issue of service connection on the merits, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). The United States Court of Appeals for the Federal Circuit has held that a veteran seeking disability benefits must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). In this case, hypertension is a chronic disease listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a chronic disease in service or continuity of symptoms after service, the disease shall be presumed to have been incurred in service. For the showing of chronic disease in service, there are required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). The Veteran's claimed erectile dysfunction is not a chronic diseases listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply as to that claim. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The law provides that 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). See Libertine v. Brown, 9 Vet. App. 521, 522 (1996); Harder v. Brown, 5 Vet. App. 183, 187 (1993). 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). Allen v. Brown, 7 Vet. App. 439, 448 (en banc). Establishing service connection on a secondary basis therefore requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service connected disability. When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board must assess the credibility and weight of all the 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 claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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. Hypertension The Veteran seeks service connection for hypertension. He contends that his hypertension is secondary to his service-connected PTSD, perhaps because of the medications he takes for his PTSD. As the Board noted in its April 2011 remand, in this case it is uncontroverted that the Veteran has been diagnosed with hypertension. The Veteran has also been granted service connection for PTSD with major depression, for avascular necrosis of the left hip, for shell fragment wound residuals of the left distal anterior thigh, for hearing loss in the left ear, and for tinnitus associated with hearing loss in the left ear. Resolution of the Veteran's hypertension claim therefore depends on whether his current hypertension disability was either caused or aggravated by a service-connected disability or the medication prescribed therefore. Service treatment records are negative for complaints or clinical findings related to high blood pressure or hypertension. During his December 1967 enlistment examination, the Veteran's blood pressure was recorded as 120/72. During his August 1970 discharge examination, the Veteran's blood pressure was recorded as 112/76. Post-service, VA medical records associated with the claims file show various blood pressure readings including: 110/75 (November 1989); 124/80 (December 1989); 122/78 (November 1990); 128/60 (October 1991); 140/90 (January 2006); 129/82 (May 2009); 158/84 and 140/78 (June 2009); 127/72 (August 2009); 135/84 (October 2009); and 130/80 (November 2009). The Veteran was scheduled for a VA examination in July 2006. It was noted that he was diagnosed with hypertension in 1995, was currently on daily Norvasc, and that his blood pressure was fairly well controlled. He reported that his blood pressure ran in the 140s/80s range when taken at home. He denied any significant sequelae of his hypertension. Blood pressure during the exam was measured as follows: 152/90, 150/86, and 142/86. Diagnosis was hypertension. The VA examiner opined that it was less likely than not that the Veteran's hypertension was related to or caused by his service-connected PTSD. After reviewing the Veteran's claims folder and providing a clinical examination, the VA examiner stated that "the [V]eteran's hypertension is less likely than not related to or caused by his PTSD. The [V]eteran is the right age for essential hypertension and the exact cause of essential hypertension is currently unknown. I do not believe the [V]eteran's hypertension has been aggravated permanently by his PTSD." A September 2006 VA medical record noted the Veteran's blood pressure was 151/87. It was noted that his hypertension was under fair control with Norvasc daily. On his July 2007 VA Form 9, Substantive Appeal, the Veteran reported that he had been told that his hypertension was caused by his PTSD. A discharge summary of the Veteran's psychiatric hospitalization at VA in May 2008 noted that the Veteran was maintained on his outpatient regimen of Benazepril and Amlodipine and that his blood pressure readings ranged from 112-168/72-92 during his stay. VA medical records dated in May 2009 and December 2009 noted that the Veteran's hypertension was currently under control. According to an October 2009 VA medical record, the Veteran reported blood pressure readings at home in the 180s to 200s systolically, but wanted his blood pressure cuff checked for accuracy. Blood pressure readings taken that day at VA measured 149/88 and 138/75. The Veteran was scheduled for another VA examination in May 2011 as a result of the Board's April 2011 remand. It was noted that the Veteran reported his hypertension was diagnosed in 1995; that since 1998 computerized records at a VA facility showed that his hypertension had been variably controlled with no trend toward either worsening or improving; and that the Veteran told the examiner that his mother had hypertension. The only symptom recounted by the Veteran was that he thought his blood pressure was high when he was angry. Blood pressure readings taken during the examination were measured as follows: 138/80; 135/78; and 139/80. Diagnosis was essential hypertension. The May 2011 VA examiner noted that the exact etiology of hypertension was not known. He stated there were multiple proposed theories in addition to many associations, such as maternal or paternal hypertension, excess alcohol intake, and obesity. The VA examiner further noted that, according to the claims file, the Veteran had hypertension prior to any sustained treatment for PTSD and current records showed no clinical decline in control of his hypertension. While PTSD or the medications used to treat it may cause a temporary aggravation of hypertension, the VA examiner stated that they would not cause it nor permanently aggravate it. The VA examiner thus opined that the Veteran's essential hypertension was not caused by nor permanently aggravated by his service-connected PTSD or the medications used to treat it. The hypertension was more likely than not caused by the Veteran's prior alcohol abuse, genetics, and obesity. In addition, the VA examiner noted the Veteran's other service-connected disabilities and stated that none of these disorders, or the medications used to treat them, are known to cause or to permanently aggravate hypertension. Therefore, he also opined that these other service-connected disabilities or the medications used to treat them did not cause or permanently aggravate the Veteran's hypertension. Based on the evidence of record, the Board finds that the preponderance of the evidence is against direct or secondary service connection for the Veteran's claim of service connection for hypertension. The Board notes that the Veteran has not contended that his hypertension is directly due to his military service. Moreover, there is nothing in the Veteran's service treatment records or elsewhere in the claims folder which suggest that such is the case. The evidence does not show, nor does the Veteran contend, that he experienced the onset of hypertension during his period of active service. His service treatment records do not reflect any complaints of, or treatment sought for, any problem related to high blood pressure during active duty. Furthermore, clinical evidence of record reflects a diagnosis of hypertension in approximately 1995. There is no evidence that the Veteran was diagnosed with hypertension before 1995, or 25 years after his separation from active service. This gap of years between discharge from service and evidence of a disease can be considered as evidence against a claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). In view of the medical evidence of record, there is no persuasive evidence of continuity of symptomatology since service, and this weighs against the Veteran's claim as well. Moreover, there is no persuasive medical evidence of record that provides a nexus to active service. The Veteran has not provided any competent medical evidence to demonstrate that any current hypertension disorder was caused by or was a result of his period of service. No one has specifically claimed that hypertension or the Veteran's blood pressure problem was at least as likely as not related to the Veteran's period of active duty. The July 2006 and May 2011 VA examiners did not suggest a direct connection between hypertension and military service in their reports. In essence, there is no competent medical opinion of record etiologically relating the Veteran's currently diagnosed hypertension to his military service. See Pond v. West, 12 Vet. App. 341 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). Without medical evidence of a nexus between a claimed disease or injury incurred in service and the present disease or injury, service connection cannot be granted. Hickson v. West, 12 Vet. App. 247, 253 (1999). In addition, presumptive service connection is not warranted for the Veteran's claim for service connection for hypertension because there is no medical evidence of record to show a diagnosis of hypertension within one year of the Veteran's separation from active service in August 1970. 38 C.F.R. §§ 3.307, 3.309. Moreover, service connection for hypertension is not warranted based on the Veteran's presumed exposure to Agent Orange while in service in Vietnam. While the Veteran served in Vietnam and currently has a hypertension disability, this disorder is not included in the list of diseases associated with herbicide exposure and, in fact, is specifically excluded in Note 2 of 38 C.F.R. § 3.309(e). Therefore, any claim for presumptive service connection for hypertension must be denied. Further, secondary service connection is not warranted for this claim. The July 2006 VA examiner found that the Veteran's hypertension was less likely as not caused by his service-connected PTSD. The May 2011 VA examiner specifically found that the Veteran's service-connected disabilities, including PTSD, and the medications used to treat them neither caused nor aggravated the Veteran's hypertension disorder. See 38 C.F.R. § 3.310. These opinions are supported by a rationale and are considered probative. Thus, service connection for hypertension on a direct, secondary, or presumptive basis is not available in this case. Therefore, the Veteran's claim for service connection for hypertension, to include as secondary to a service-connected disability, must be denied. Erectile Dysfunction The Veteran seeks service connection for erectile dysfunction. He contends in his December 2005 claim that his erectile dysfunction is due to the medication he takes for his service-connected psychiatric disorder. A June 2006 statement from A.R., M.D. indicated that the Veteran had been treated in his private office for erectile dysfunction which "may be related to" his hypertension and hyperlipidemia. Previous medications listed included: Norvasc, Prozac, Xanax, Ibuprofen, and Viagra. A September 2006 VA medical record noted that the Veteran had erectile dysfunction for which he had used Viagra in the past. It was noted that the Veteran was no longer taking Viagra and was interested in getting another medication through VA. Vardenafil was ordered. According to an October 2009 VA medical record, the Veteran had reported decreased libido and difficulties with erections in August 2008, but testosterone and other hormone labs were within normal limits. A VA endocrinologist fellow noted that the Veteran's decreased libido was a chronic problem of at least two years duration and was likely related to his antidepressants or other medications. In January 2010, the Veteran was afforded a VA examination to determine whether his erectile dysfunction was secondary to the medication taken for his service-connected psychiatric disorder. The Veteran told the examiner that he thought he had problems with sexual dysfunction beginning about 10 years before. He said that the erectile dysfunction seemed to come on gradually. At first his erections were not as firm or lasted as long and then gradually got worse. He then reached the point that he was not able to have any sort of erection. Prior to starting Viagra he could not recall if he was able to have any sort of erection. When he started Viagra he might have been able to have an erection a couple of times. It then quit working even when he took three pills. He was then switched to Cialis and that did not help. He then went to the VA and was given a prescription for Vardenafil that did not help at all. He estimated that he had not had an erection satisfactory for vaginal penetration for about 10 years. When asked if he could associate erectile dysfunction with anything, the Veteran said that it might be related to his depression because the depression seemed to get bad for a period of time and then he was unable to have any more erections. He could not recall if he was on psychiatric medications when the erectile dysfunction first started. He did not think that he was on psychiatric medications when the erectile dysfunction began, but he could not really recall. The erectile dysfunction did not cause any urinary frequency, incontinence, renal dysfunction, or vocational limitations. Diagnosis was erectile dysfunction. The VA examination report noted that the Veteran had not been on any psychiatric medications for any significant period of time prior to January 2006, when he took Prozac. The Veteran said that his family doctor had prescribed Prozac about four years earlier and that he took it daily. After reviewing the Veteran's medical records and providing a clinical examination, the VA examiner noted that the medical records "do not associate the onset of [the Veteran's erectile dysfunction] with the prescribing of his psychiatric medications." The examiner also noted that the Veteran "has multiple risk factors for [erectile dysfunction] including alcohol, and tobacco use, advancing age, low testosterone and hypertension." She opined that it was not as likely as not that the Veteran's erectile dysfunction was secondary to the medications he was prescribed for his service-connected psychiatric conditions. The Veteran was scheduled for another VA examination in May 2011 as a result of the Board's April 2011 remand. After reviewing the claims file, the VA examiner concurred with the history recounted in the January 2010 VA examination. The Veteran's wife said that the Veteran's erectile dysfunction started about 15 years ago. The Veteran reported that he thought he first started taking medications for this in the mid-1990s about the time his hypertension was diagnosed. He currently used no medication or treatments because nothing had worked and he was unable to have an erection at all. The May 2011 VA examiner noted that documented records showed other multiple risk factors for erectile dysfunction, including: low testosterone values, chronic alcohol abuse, hypertension, smoking, obesity, and aging. While any mental health condition, or the medications used to treat such, can temporarily cause erectile dysfunction, the VA examiner stated that this was not permanent. It was also not clear from the Veteran's records that there is a specific association between his psychiatric medications or PTSD and his erectile dysfunction. Therefore, the May 2011 VA examiner opined that the Veteran's erectile dysfunction was less likely than not caused by or permanently aggravated by his service-connected PTSD or the medications used to treat it. The examiner felt that the erectile dysfunction was more likely than not due to the other risk factors noted above. The VA examiner also noted that the record evidence suggested that the Veteran's erectile dysfunction and hypertension began or were diagnosed at about the same time. Therefore, as hypertension takes years to cause erectile dysfunction, the Veteran's erectile dysfunction was less likely than not caused by his hypertension. However, because hypertension is a known risk factor for erectile dysfunction and the Veteran had variable control of his hypertension, it was at least as likely as not that his hypertension permanently aggravated his erectile dysfunction. The VA examiner noted that it was impossible to state when this aggravation exactly occurred. The VA examiner also noted that medications used to treat hypertension can temporarily aggravate erectile dysfunction but they do not cause it or permanently aggravate it. Based on the evidence of record, the Board finds that the preponderance of the evidence is against direct or secondary service connection for the Veteran's claim of service connection for erectile dysfunction. The Board notes that the Veteran has not contended that his erectile dysfunction is directly due to his military service. Moreover, there is nothing in the Veteran's service treatment records or elsewhere in the claims folder which suggest that such is the case. The evidence does not show, nor does the Veteran contend, that he experienced the onset of erectile dysfunction during his period of active service. His service treatment records do not reflect any complaints of, or treatment sought for, any problem related to erectile dysfunction during active duty. Furthermore, clinical evidence of record reflects an assessment of erectile dysfunction in 2006. During his May 2011 VA examination, the Veteran estimated the onset of erectile dysfunction in approximately 2000 and his wife said it might have been in 1996, or 26 to 30 years after his separation from active service in August 1970. This gap of years between discharge from service and evidence of a disease can be considered as evidence against a claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Moreover, there is no medical evidence of record that provides a nexus to active service. The Veteran has not provided any competent medical evidence to demonstrate that any current erectile dysfunction disorder was caused by or was a result of his period of service. No one has specifically claimed that the Veteran's erectile dysfunction was at least as likely as not related to the Veteran's period of active duty. The January 2010 and May 2011 VA examiners did not suggest a direct connection between erectile dysfunction and military service in their reports. In essence, there is no competent medical opinion of record etiologically relating the Veteran's currently diagnosed erectile dysfunction to his military service. See Pond v. West, 12 Vet. App. 341 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). Without medical evidence of a nexus between a claimed disease or injury incurred in service and the present disease or injury, service connection cannot be granted. Hickson v. West, 12 Vet. App. 247, 253 (1999). Further, secondary service connection is not warranted for this claim. The January 2010 VA examiner found that the Veteran's erectile dysfunction was less likely as not caused by his service-connected PTSD or his psychiatric medications. The May 2011 VA examiner specifically found that the Veteran's PTSD, and the medications used to treat his psychiatric condition, neither caused nor aggravated the Veteran's erectile dysfunction disorder. See 38 C.F.R. § 3.310. These opinions are supported by a rationale and are considered probative. While a VA endocrinologist noted in October 2009 that the Veteran's decreased libido was likely related to his antidepressants or other medications, the Board finds this opinion is much too indeterminate to support an award of service connection. First, the VA endocrinologist did not explicitly refer to erectile dysfunction when discussing a decreased libido. Second, while she may have inferred that the Veteran's erectile dysfunction was caused or aggravated by medications taken for his service-connected PTSD and depression, because she said it was likely related to antidepressants or some other unspecified medications, the Board notes that the inference could also be drawn that the Veteran's erectile dysfunction was likely related to those other unspecified medications that may have been taken for a nonservice-connected disorder. As the January 2010 and May 2011 VA opinions are probative and supported by a rationale, the Board finds they outweigh the one-sentence conclusory and opaque statement of the VA endocrinologist found in the October 2009 VA medical record. While the May 2011 VA examiner opined that the Veteran's hypertension had permanently aggravated the Veteran's erectile dysfunction, secondary service connection is not in order in this case as the disability at issue, erectile dysfunction, is not proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310(a); Libertine v. Brown, 9 Vet. App. 521, 522 (1996); Harder v. Brown, 5 Vet. App. 183, 187 (1993). As explained in the section immediately above, the Board found that direct or secondary service connection for hypertension was not warranted. Therefore, nonservice-connected hypertension cannot be the basis for secondary service connection for any other disorder, such as erectile dysfunction. Finally, there is no persuasive medical evidence in the record that any of the Veteran's other service-connected disabilities, such as his left hip and left thigh disorders or his tinnitus and hearing loss, caused or aggravated his erectile dysfunction. Rather, the May 2011 VA examiner specifically found that it was more likely than not that the Veteran's erectile dysfunction was due to such risk factors as low testosterone values, prior chronic alcohol abuse, smoking, obesity, aging, and the Veteran's nonservice-connected hypertension. Thus, service connection for erectile dysfunction on a direct or secondary basis is not available in this case. Therefore, the Veteran's claim for service connection for erectile dysfunction, to include as secondary to a service-connected disability, must be denied. Conclusion In reviewing the Veteran's claims the Board has reviewed the written statements of the Veteran and his representative. Lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995). The Veteran is certainly competent to describe the extent of his current symptomatology and the continuity of symptomatology from service onwards. The Board notes, however, that there is no evidence that the Veteran possesses the requisite medical training or expertise necessary to render him competent to offer evidence on matters such as a medical diagnosis of hypertension or the causal questions of whether his hypertension or erectile dysfunction can be attributed to his service-connected PTSD, to his medications for other service-connected disabilities, or to his in-service experiences. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Given the absence of persuasive evidence in support of the Veteran's claims, for the Board to conclude that the Veteran has hypertension and/or erectile dysfunction incurred as a result of his period of active service or secondary to any of his service-connected disabilities would be speculation, and the law provides that service connection may not be based on a resort to speculation or remote possibility. 38 C.F.R. § 3.102; Obert v. Brown, 5 Vet. App. 30, 33 (1993). Accordingly, the Board finds that the preponderance of the evidence is against these claims for service connection for hypertension and for erectile dysfunction. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against his claims. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Service connection for hypertension, to include as secondary to a service-connected disability, is denied. Service connection for erectile dysfunction, to include as secondary to a service-connected disability, is denied. ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs