Citation Nr: 1326996 Decision Date: 08/22/13 Archive Date: 08/29/13 DOCKET NO. 09-03 432A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for erectile dysfunction, due to prostate surgery for service-connected prostate cancer. 2. Entitlement to service connection for left lower extremity numbness and pain, due to prostate surgery for service-connected prostate cancer. 3. Entitlement to service connection for right lower extremity numbness and pain, due to prostate surgery for service-connected prostate cancer. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD J. Schulman, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from April 1967 to April 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico, which denied service connection for the issues listed above. The Veteran appealed the denials of service connection in this decision, and the matter is now before the Board. Since initial adjudication by the RO in Albuquerque, jurisdiction for the claims was transferred to the RO in Waco, Texas. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal that are not already of record. FINDINGS OF FACT 1. The Veteran did not engage in combat with the enemy during service. 2. The Veteran did not sustain a disease or injury related to erectile dysfunction in service. 3. Erectile dysfunction is not etiologically related to service, or a service-connected disability, and was not aggravated by a service-connected disability. 4. The Veteran did not sustain a disease or injury related to his lower extremities in service. 5. Current lower extremity numbness and pain is not etiologically related to service, or a service-connected disability, and was not aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. Erectile dysfunction was not incurred in service, may not be presumed to have been incurred therein, and was not proximately caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2012). 2. Lower extremity numbness and pain was not incurred in service, may not be presumed to have been incurred therein, and was not proximately caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duties 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). VCAA notice should be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the RO provided a VCAA notice letter to the Veteran in November 2007, prior to the initial adjudication of the service connection claims. The letter notified the Veteran of what information and evidence must be submitted to substantiate the claims, including how to substantiate the claims on a secondary basis, and a description of what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. The Veteran was also advised to inform VA of any additional information or evidence that VA should have, and to submit evidence in support of the claims to the RO. The content of the letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The notice requirements of the VCAA apply to all elements of a service connection claim, including: (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 of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In this case, notice compliant with Dingess has not been sent to the Veteran with regard to information about the types of evidence necessary to establish a disability rating or an effective date for any of the specific claims on appeal if a rating is granted. Nonetheless, because the Board finds that service connection is not warranted for the issues on appeal, no ratings or effective dates will be assigned and any questions as to such assignments are rendered moot. Based on the foregoing, timely and adequate notice was provided to the Veteran prior to the transfer and certification of this case to the Board and complied with the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist a veteran in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2012); see Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010) (stating that the "duty to assist is not boundless in its scope" and "not all medical records . . . must be sought - only those that are relevant to the veteran's claim"). In this case, service records have been obtained, as have records of private and VA treatment. These pertinent records have been associated with the Veteran's claims file and reviewed in consideration of the issues before the Board. The Veteran was afforded VA examinations in January 2008 and June 2013, during which the examiners conducted physical examinations of the Veteran, were provided the claims file for review, took down the Veteran's history, considered the lay evidence presented, laid factual foundations for the conclusions reached, and reached conclusions and offered opinions based on history and examinations that are consistent with the record. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2012); Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of their opinion). The Board finds that all necessary development has been accomplished; therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In addition to the evidence discussed above, the Veteran's statements in support of the claims are also of record. The Board has carefully considered such statements and concludes that no available outstanding evidence has been identified. Additionally, the Board has reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. For these reasons, the Board finds that the duties to notify and assist the Veteran in the development of these claims have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The Veteran's lower extremity symptoms have been characterized as potentially related to a nerve disorder, to include neuropathy. Organic disease of the nervous system are "chronic diseases" under 38 C.F.R. § 3.309(a); therefore the presumptive provisions of 38 C.F.R. § 3.303(b) apply in the case of such disorders. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Therefore, to the extent that either the Veteran's claimed bilateral low extremity symptoms or claimed erectile dysfunction are organic diseases of the nervous system, the presumptive provisions apply. ("Neuropathy is defined as a general term denoting functional disturbances and/or pathological changes in the peripheral nervous system." Ferraro v. Derwinski, 1 Vet. App. 326, 329 (1991) and Kellar v. Brown, 6 Vet. App. 157, 161 (1994). "Neuropathy is a 'disorder affecting any segment of the nervous system.'" Russo v. Brown, No. 93-814, slip op. at 3 (U.S. Vet. App. Apr. 2, 1996). "Neuropathy is an abnormal and usually degenerative state of the nervous system or nerves." Nix v. Brown, 4 Vet. App. 462, 466 (1993).). 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. In order to show a "chronic" disease in service, the record must reflect a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Where a chronic disease has been incurred 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 in order to establish entitlement to service connection. 38 C.F.R. § 3.303(b Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, including neuropathy to the extent that it is an organic disease of the nervous system, become manifest to a degree of 10 percent or more within one year after the date of separation from such 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. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. In this case, the Veteran is contending that the claimed disorders are residuals of surgery related to service-connected prostate cancer. Except as provided in 38 C.F.R. § 3.300(c), a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (2012). This includes any increase in disability (aggravation) that is proximately due to or the result of a service connected disease or injury. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused or aggravated by service. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). When aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen, supra. Thus, in this case, in order to warrant service connection for erectile dysfunction or a lower extremity disorder on a secondary basis, the evidence must show that erectile dysfunction or a lower extremity disorder was caused or aggravated by a service-connected disease or injury (disability). Effective October 10, 2006, the section heading of 38 C.F.R. § 3.310 was retitled "Disabilities that are proximately due to, or aggravated by, service-connected disease or injury." Paragraph (b) of 38 C.F.R. § 3.310 was redesignated as paragraph (c), and a new paragraph (b) was added, which describes a requirement for VA to establish a baseline for a disability before adjudicating the question of unnatural progression of that disability due to a service-connected disease or injury. Here, however, the claim on appeal was received by VA prior to October 10, 2006, and thus the revisions to 38 C.F.R. § 3.310 are not for application in the immediate case. Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Erectile dysfunction is a disability capable of lay observation, and lower extremity numbness and pain are symptoms capable of lay observation. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the 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. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A layperson is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Court has held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Court has also stated, "[i]t is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. As previously stated, the Veteran contends that the claimed disorders are related to post-service surgery for prostate cancer. The Veteran does not allege that the claimed disorders were incurred as a result of combat against enemy forces; thus, the provisions of 38 U.S.C.A. § 1154(b) (West 2002) are not for application. Service Connection of Erectile Dysfunction The Board finds erectile dysfunction did not manifest in service, and neither did the Veteran sustain a disease or injury related to his current erectile dysfunction in service. Service treatment records do not reflect any complaint referable to the genitals in general or erectile dysfunction specifically, including on service separation examination in January 1971. The Veteran first endorsed erection-related problems in an October 2005 private medical evaluation, 34 years after separation from service. At that time, the Veteran indicated "yes" when asked "Have you had: difficulty with erections" on a health assessment questionnaire. In his April 2008 notice of disagreement, the Veteran clarified that, when asked the same question orally during his October 2005 doctor's visit, he replied "erections did not occur as quickly as 30 years ago, but [he] did not need any assistance." The Board finds that the Veteran's erectile dysfunction is not etiologically related to a service-connected disability, and has not been permanently worsened by a service-connected disability. In June 2007 the Veteran reported to a VA medical provider that he had recently undergone prostate surgery. He felt the surgery had been a success, but "complain[ed] or residuals like loss of creative organ, incontinence, and pain & numbness in lower extremities." On VA examination January 2008, it was noted that the Veteran endorsed difficulty with erections in October 2005, "long before his [prostate] surgery." The Veteran reported to the examiner that prior to his prostate surgery in May 2007, he had no erectile dysfunction symptoms, but that erectile dysfunction symptoms immediately followed the surgery and had persisted ever since. The VA examiner opined that erectile dysfunction was not caused by or a result of the Veteran's service-connected prostate surgery. In so concluding, the examiner noted again that the Veteran had "stated he had this complaint long before he had prostate cancer or surgery for same" and thus, "clearly today's story is a lie." An April 2008 letter from private physician, Dr. M.L.A., stated that the Veteran was "suffering from post-prostatectomy . . . impotence," which was described as "common with this type of surgery." The Veteran was being given time to spontaneously correct the problem, and was also being treated medically with Cialis. In June 2013, a VA examiner reviewed the Veteran's claims file with regard to erectile dysfunction and its relationship to the Veteran's prostate surgery. The examiner opined that erectile dysfunction is a multifactorial process. The examiner stated that, according to the medical reference UpToDate, "In addition to age, the best predictors of erectile dysfunction are diabetes mellitus, hypertension, obesity, dyslipidemia, cardiovascular disease, smoking, and medication use." The examiner noted that the Veteran had a greater than 50 percent chance of developing erectile dysfunction due to his age alone. The examiner recognized that the Veteran endorsed worsening of erectile dysfunction following his prostate surgery, but opined that onset of erectile dysfunction was likely due to a combination of individual risk factors. The examiner also stated that, "because of the myriad of variables at play, current medical knowledge cannot accurately discern the exact amount of dysfunction due to each specific risk factor. Therefore, the issue of whether the prostatectomy aggravated the [erectile dysfunction] cannot be determined without resorting to speculation." An additional VA examination was conducted later in June 2013. At this examination, the examiner clarified that an in-person examination of the Veteran was being conducted, and that the Veteran's claims file was reviewed. Following a review of the claims file and a physical examination, the examiner concurred with the opinion of the previous VA examiner, and added that: there is not enough medical evidence to support the claim that [the Veteran's erectile dysfunction] was exacerbated by prostatectomy alone. Because there are multiple other risk factors for [erectile dysfunction], it is not as likely as not that the Veteran's [erectile dysfunction] is due to, caused by or exacerbated by prostatectomy. The Veteran is competent to state, as he has, that prior to his prostate surgery he did not have difficulty with erections. Layno v. Brown, 6 Vet. App. 465 (1994). Nonetheless, while competent, to the extent that the Veteran denies any erectile dysfunction prior to his prostate surgery, the Board finds such a claim to be not credible in light of his 2005 endorsements of difficulty with erections; thus, the Board finds that the evidence shows that the Veteran had some erectile symptoms prior to the 2007 prostate surgery. Having established that erectile symptoms predated 2007 surgery, the Board is left to consider whether erectile dysfunction underwent a worsening due to the prostate surgery. In considering the medical opinions of record, the Board notes that a VA medical examination is not inadequate merely because the medical examiner states he or she cannot reach a conclusion without resort to speculation. Jones v. Shinseki, 23 Vet. App. 382 (2011). Thus, while VA has a duty to assist a veteran by providing a medical examination in certain situations, that duty does not extend to requiring a VA physician to render an opinion beyond what may reasonably be concluded from the procurable medical evidence. Nevertheless, simply concluding that the etiology of a disability could not be resolved without speculation, without providing any explanation why, renders an opinion inadequate. Id. The phrase "without resort to speculation" should reflect the limitations of knowledge in the medical community at large and not those of a particular examiner. Further, the examiner should clearly identify precisely what facts cannot be determined. For example, it should be clear in the examiner's remarks whether it cannot be determined from current medical knowledge that a specific in-service injury or disease can possibly cause the claimed condition, or that the actual cause cannot be selected from multiple potential causes. Id. Here, with respect to the June 2013 VA examination opinions, the Board finds the opinions are highly probative. The examinations are not only consistent with each other, but also include reference to medical treatise documentation for the proposition that the question of erectile dysfunction causation and/or aggravation in this case is beyond the reach of medical science given the Veteran's other risk factors. The Board has also considered the April 2008 letter from Dr. M.L.A. in which he describes the Veteran's erectile dysfunction as "post-proctectomy impotence." Dr. M.L.A. stated that the Veteran's "post-prostatectomy impotence" may "spontaneously correct." However, while the evidence demonstrates that the Veteran nonetheless still has erectile dysfunction, as the June 2013 VA opinions note, "there is not enough medical evidence to support the claim that [the Veteran's erectile dysfunction] was exacerbated by prostatectomy." Thus while erectile dysfunction may have become worse around the same time as the Veteran's prostatectomy, the weight of the evidence shows that attributing any additional worsening to the prostate procedure would be mere speculation. Based on the foregoing, the Board finds that the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for Bilateral Lower Extremity Numbness and Pain The Veteran contends that he currently has a disability of both lower extremities that is indicated by numbness and pain. After a review of all the evidence, the Board finds that a lower extremity disability did not manifest in service, and the Veteran did not sustain a disease or injury related to his low extremities during service. Service treatment records are silent for complaints referable to lower extremity numbness or pain. The service separation examination report date in January 1971 reflects findings of normal lower extremities. The Board finds that weight of the evidence demonstrates that the Veteran's current lower extremity disability was not caused by service or caused or aggravated by a service-connected disability. The record indicates that the Veteran did not develop lower extremity symptoms until after the post-service May 2007 prostate surgery about 37 years after service. On VA examination in January 2008, the Veteran reported to the examiner that he first developed numbness and pain in June or July 2007, following the May 2007 prostate surgery. Symptoms included trouble controlling his right leg when walking. The Veteran endorsed a 40-year history of low back pain, but without any history of leg problems until the post-service surgery in May 2007. At the time of the VA examination in January 2008, the Veteran had weakness, stiffness, numbness, pain, and impaired coordination in the right leg, from the hip to the leg. On physical examination, muscle strength was normal in all major muscle groups of both lower extremities. Sensory function testing showed reduced pinprick across all five toes, but not in a radicular distribution. The examiner diagnosed "subjective right leg numbness and pain," and, having found no disability, did not offer an opinion regarding the relationship between any lower extremity symptomatology and the Veteran's service-connected prostate surgery. The Veteran underwent electromyography and nerve conduction studies in February 2008 at a VA medical center. The Veteran complained of numbness and tingling down the right lateral thigh and calf, as well as some numbness in the groin area. He felt that his right leg was not as coordinated, and that others had pointed out to him that when he walks "he swings his right leg wide." The Veteran reported that he had first noted symptoms following the May 2007 prostate surgery. On physical examination, no atrophy was noted in the foot intrinsics, and sensation to touch and temperature at the toes was normal. Strength was five out of five in both legs, except in the right hamstring where muscle strength was four out of five. The impression was that testing results were consistent with recovered L5 radiculopathy, but that the age of the radiculopathy could not be determined. In an April 2008 statement, the Veteran indicated that he had undergone neurologic testing at the VA hospital in Albuquerque and was told that he had permanent damage to nerve 5, but the testing physician "could not state whether it occurred in the last year or 30 years ago." The Veteran went on to state that "pain and numbness in the left lower extremity has resided [sic] in the last three months, but not the right side." The Veteran continued to have numbness, and his right leg did not always "operate in a normal way" when walking. A May 2010 letter from the Veteran's wife said that she had spoken with the Veteran's private physician, Dr. M.L.A., regarding the Veteran's February 2008 VA nerve study. She indicated that Dr. M.L.A. had not previously been made aware of the results of the study, so she "reviewed the findings with him and he agreed that he also could not definitely say that [numbness in the Veteran's legs] was because of the surgery." On VA examination in June 2013, the examiner reviewed the claims file and opined that the Veteran had a spastic hemiparesis due to a 2009 stroke. The Veteran's physical examination was "not consistent with a diagnosis of peripheral neuropathy." The examiner went on to note that according to the medical reference UpToDate, peripheral neuropathy is not a recognized complication of prostatectomy. Furthermore, the Veteran did not meet the clinical criteria for a diagnosis of peripheral neuropathy. On follow-up VA examination in June 2013, an in-person examination of the Veteran was conducted as was a review of the claims file. The examiner concluded that the Veteran did not have a peripheral nerve condition or peripheral neuropathy. Rather, the only diagnosed disorders were of right hemiparesis from stroke, and "radiculopathy - right L3 old and recovered." In statements submitted to VA and to VA examiners, the Veteran has indicated that his legs have been painful, numb, and not stable since 2007. These endorsed symptoms are capable of lay observation, and thus the Veteran's statements of such symptoms in the left foot are competent. Jandreau; Layno, 6 Vet. App. 465. Nonetheless, the Veteran himself has not indicated an underlying pathology associated with his lower extremities. Furthermore, while the Veteran is competent to state that he first noticed lower extremity symptoms following his 2007 prostate surgery, he is not competent to link the two, nor is he competent to state that a permanent worsening has occurred as a result of his prostate surgery. The competent evidence shows that the Veteran's only current disorders affecting the lower extremities include residuals of a post-service 2009 stroke and radiculopathy at the L5 level. Neither the lay or medical evidence associates either of these disorders with a service-connected disease or injury, including the prostate surgery. Thus, in total the weight of the evidence shows that the Veteran's lower extremity numbness and pain are not related to service, and are not caused or aggravated by a service-connected disability. As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for erectile dysfunction, to include as secondary to service-connected prostate surgery, is denied. Service connection for left lower extremity numbness and pain, to include as secondary to service-connected prostate surgery, is denied. Service connection for right lower extremity numbness and pain, to include as secondary to service-connected prostate surgery, is denied. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs