Citation Nr: 1328023 Decision Date: 09/03/13 Archive Date: 09/10/13 DOCKET NO. 07-24 784 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Whether the reduction of the Veteran's disability rating for adenocarcinoma of the prostate from 100 percent to noncompensable, effective April 1, 2006, was proper, to include entitlement to a compensable evaluation for the period beginning on that date and entitlement to a rating in excess of 20 percent from September 24, 2010. 2. Entitlement to a disability evaluation in excess of 10 percent disabling for diarrhea. 3. Entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Marenna, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1967 to October 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, and July and August 2007 rating decisions from the RO in Boise, Idaho. Jurisdiction was subsequently transferred to the Atlanta, Georgia, RO. In June 2010, the Veteran testified during a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. This case was previously before the Board in August 2010 and remanded for additional development. For the reasons discussed below, the Board finds that there has been substantial compliance with the mandates of the August 2010 remand. See Stegall v. West, 11 Vet. App. 268 (1998) In a February 2012 rating decision, the RO granted entitlement to an evaluation of 20 percent for adenocarcinoma of the prostate, from September 24, 2010. The Court has held that a "decision awarding a higher rating, but less than the maximum available benefit . . . does not . . . abrogate the pending appeal . . . ." AB v. Brown, 6 Vet. App. 35, 38 (1993). As the rating decision did not grant the Veteran's increased rating claim in full, the issue remains before the Board. The issue of entitlement to a TDIU has been raised by the record and is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT 1. The RO's decision to reduce the evaluation for residuals of prostate cancer from 100 percent was supported by the evidence contained in the record at the time of the reduction, and was made in compliance with applicable due process laws and regulations. 2. From April 1, 2006, the residuals of prostate cancer manifested as voiding dysfunction requiring the wearing of absorbent materials of up to 3 times per day and increased frequency. 4. During the period on appeal, the Veteran's service-connected diarrhea was manifested by moderate diarrhea with frequent episodes of bowel disturbance with abdominal distress and occasional involuntary bowel movement, necessitating wearing of a pad. CONCLUSIONS OF LAW 1. The reduction of the evaluation for residuals of prostate cancer from 100 percent effective April 1, 2006, was proper. 38 U.S.C.A. § 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.105(e), 4.115b, Diagnostic Code 7528-7527 (2012). 2. The criteria for a disability evaluation of 40 percent, but no higher, for residuals of prostate cancer from April 1, 2006, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.114, 4.115a, Diagnostic Code 7528-7527 (2012). 3. The criteria for a disability evaluation of 30 percent have been met for diarrhea. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.114, Diagnostic Codes 7399-7527, 7332. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). 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). 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 claimant. 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. 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. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In regard to the Veteran's appeal of the reduction of the disability rating for adenocarcinoma of the prostate, the appeal does not arise from adjudication of a claim made by the Veteran. Rather, it arises from a rating reduction initiated by the RO. A rating reduction requires compliance with particular notification procedures under the law, which require that specific notice be given to the Veteran before the adjudication takes place. See 38 C.F.R. § 3.105(e), (i). Moreover, these procedures require that the Veteran be given an opportunity to respond to the proposed action not only to submit evidence relevant to the issue of the reduction, but also to request a predetermination hearing. The RO complied with these notification procedures. However, the July 2007 statement of the case did not set forth the provisions of 38 C.F.R. § 3.105. In compliance with the August 2010 Board remand, the Veteran received notice of 38 C.F.R. § 3.105(e) in a January 2012 supplemental statement of the case. See Stegall v. West, 11 Vet. App. 268 (1998). Thus, the Board finds the notification requirements have been met in regard to the rating reduction claim. First, the Board finds that the timing of the notice requirement was met in this case. As noted above, the regulations governing notice of a proposed reduction require that notice be given before the adjudication, and this was done in this case. Specifically, the Veteran was given notice of an initial proposed reduction evaluation in July 2005 before the rating was reduced in a December 2005 rating decision, effective April 1, 2006. Therefore, in accordance with Pelegrini, the timing of the notice requirement was met in this case and to decide the appeal would not be prejudicial error to the claimant. Second, the requirements with respect to the content of the notice were met in this case. Notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. In this case, the RO informed the Veteran in the July 2005 notice of proposed reduction that he may submit medical evidence to show that the RO should not make the change that it proposed to make in the rating assigned for his service- connected prostate disability. The RO also informed him of his right to a hearing. In the attached rating decision proposing the reduction, the RO informed the Veteran of the evidence it had considered in reaching its determination and advised him of the rating criteria used to evaluate the evaluate the degree of disability associated with his prostate disability. Here the Veteran is appealing the initial rating assignment as to diarrhea due to radiation treatment for adenocarcinoma of the prostate. In this regard, because the July 2007 rating decision granted service connection, such claim is now substantiated. In an October 2007 supplemental statement of the case, the RO clarified that they made a technical correction to his rating separating the service-connected diarrhea from residuals of prostate cancer. The RO noted that it would address both issues because they had intertwined them. As the issue is intertwined, the Veteran's appeal does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3). Rather, the Veteran's appeal here triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. As a consequence, VA is only required to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here. The July 2007 statement of the case (SOC), under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," set forth the relevant diagnostic code (DC) for rating the disability at issue, and included a description of the rating formulas for all possible schedular ratings under this diagnostic code. The Veteran was thus informed of what was needed not only to achieve the next-higher schedular rating, but also to obtain all schedular ratings above the initial evaluation that the RO assigned. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve a higher rating for the service-connected disability at issue. Additionally, in a May 2008 letter, the correspondence informed the Veteran of the rating criteria for his service-connected diarrhea. VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file, as requested in the August 2010 remand. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran with an appropriate VA examination in September 2010. As discussed in the August 2010 remand, the Veteran failed to report for a VA genitourinary examination in July 2005 and he failed to keep VA consistently apprised of his whereabouts during a portion of the period on appeal. The September 2010 examination is adequate because it is based on a thorough examination, a description of the Veteran's pertinent medical history, and appropriate diagnostic tests. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the Veteran's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disorder since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. The September 2010 VA examination report is thorough and provided findings pertinent to the rating criteria. The examination in this case is adequate upon which to base a decision. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). III. Rating Reduction and Increased Rating Claims Disability evaluations are determined by comparing a veteran's present symptomatology with the criteria set forth in the Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 4.1 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. 38 C.F.R. § 4.1. Nevertheless, where, as here, the Veteran is appealing the rating for an already established service-connected condition, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Reduction An October 2004 rating decision granted service connection for adenocarcinoma of the prostate with an evaluation of 100 percent effective June 29, 2004. A December 2005 rating decision, which is the subject of this appeal, reduced the 100 percent rating to noncompensable effective April 1, 2006. In a February 2012 rating decision, the RO determined that the Veteran was entitled to a 20 percent disability rating for residuals of adenocarcinoma of the prostate, effective September 24, 2010. The Veteran has also been granted entitlement to service connection for diarrhea associated with adenocarcinoma of the prostate, effective April 1, 2006. The VA rating schedule sets forth the criteria for evaluation of the genitourinary system-diagnoses under 38 C.F.R. § 4.155b. Malignant neoplasms of the genitourinary system are rated under Diagnostic Code 7528, which states that, following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent evaluation shall be subject to the provisions of 38 C.F.R. § 3.105(e). If there has been no local reoccurrence or metastasis, the rating will be based on residuals as voiding dysfunction or renal dysfunction, whichever is predominant. Here, the Veteran was rated as noncompensable because he did not attend the mandatory VA examination scheduled in July 2005. A VA treatment record noted that the phone number left by the Veteran was for a store and they said he had moved to California. The RO issued a rating decision later in July 2005 proposing to reduce the Veteran's 100 percent disability rating to noncompensable because no examination took place. A copy of the rating decision, as well as a letter explaining the Veteran's rights to submit evidence and request a hearing regarding the proposed reduction, was mailed to his last address of record in Florida. The Veteran did not respond. A RO rating decision dated in December 2005 thereafter reduced his disability evaluation from 100 percent to noncompensable. Once again, a copy of the rating decision was mailed to the Veteran's last address of record in Florida. VA next heard from the Veteran in May 2006, when he submitted a notice of disagreement with the December 2005 decision. At that time, he indicated that he had not received proper notification of the reduction and that he lived in Georgia. In a statement dated that same month, the Veteran requested an examination to address the residuals of his disability. The RO indicated in its July 2007 statement of the case however, that an examination was not necessary because the medical evidence of record was sufficient to adjudicate the Veteran's claim. Subsequent supplemental statement of the cases reiterated this point. As discussed in the August 2010 remand, the Veteran bears the burden of apprising VA of his whereabouts, and if he does not do so, there is no burden on the part of VA "to turn up heaven and earth" to find him. Hyson v. Brown, 5 Vet. App. 262, 265 (1993). From the above history, it is clear that the Veteran's failure to keep VA so apprised contributed to the cancellation of his July 2005 VA genitourinary examination. It also is clear, however, that another VA genitourinary examination could have been scheduled for the Veteran after he resurfaced in Georgia. In the interest of obtaining a complete record upon which to decide his claim, the Board requested that the Veteran be scheduled for a VA examination in the August 2010 remand. The Board finds that the reduction from a 100 percent rating was proper. The Veteran failed to report for the July 2005 VA examination and failed to keep VA informed of his current address. In the July 2005 rating decision, the RO informed the Veteran that the evaluation of adenocarcinoma of the prostate, which was currently 100 percent disabling, was proposed to be decreased to 0 percent. The RO provided notice in compliance with 38 U.S.C.A. § 3.105(e), notifying the Veteran that he may submit medical or other evidence to show that they should not make this change and that he has the right to request a personal hearing. The Veteran did not respond to the RO within the 60-day time limit set forth in the regulation. 38 C.F.R. § 3.105(e). Nor did he inform VA of any instances of radiation, chemotherapy, or other treatment for active-stage prostate cancer since April 2006. At the June 2010 hearing, the Veteran stated that his rating was reduced approximately a year after he finished treatment for prostate cancer. See June 2010 Board Hearing Transcript (Tr.) at p. 3. There is no ether evidence of such treatment in the claims file. In fact, the record reflects that his cancer has remained in remission with no recurrence of the disease. In the December 2005 rating decision, the RO reduced the Veteran's rating to 0 percent effective April 1, 2006, for an evaluation of adenocarcinoma of the prostate. The Board finds that the weight of the evidence shows that the Veteran's service-connected prostate disorder had undergone actual improvement. Accordingly, the Veteran no longer met the criteria for a 100 percent schedular evaluation. 38 C.F.R. § 4.115b, Diagnostic Code 7528. Therefore, the Board finds that the criteria for a reduction in the Veteran's prostate disability rating were met, and restoration of his total schedular evaluation is unwarranted. Increased Rating Claims The Board's analysis does not end here, however, because the Veteran disagrees with the assigned noncompensable rating from April 1, 2006. There has been no recurrence of the Veteran's active-stage prostate cancer since his surgery. Thus, residuals are to be evaluated based on renal or voiding dysfunction, whichever is predominant. 38 C.F.R. § 4.115b, Diagnostic Code 7528. Under the renal dysfunction criteria set forth in 38 C.F.R. § 4.115a, a 30 percent rating is warranted for albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101. A 60 percent rating is warranted for constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101. An 80 percent rating is assignable for persistent edema and albuminuria with BUN [blood urea nitrogen] 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. Finally, a 100 percent rating is appropriate for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. In this case the Veteran has not alleged, and the evidence does not show, that his prostate cancer disability has been accompanied by any of the aforementioned symptoms of renal dysfunction. Accordingly, the Board has no basis to assign a higher rating under these criteria. As for voiding dysfunction, VA regulations provide that the disability is to be rated as a particular condition as urine leakage, frequency, or obstructed voiding. 38 C.F.R. § 4.115a. Continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence which requires the wearing of absorbent materials which must be changed less than 2 times per day is to be rated as 20 percent disabling. A 40 percent rating is warranted when such impairment requires the wearing of absorbent materials which must be changed 2 to 4 times per day. A 60 percent rating requires the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day. Id. Urinary frequency with a daytime voiding interval between two and three hours, or awakening to void two times per night, warrants a 10 percent rating. A 20 percent rating is warranted when there is a daytime voiding interval between one and two hours, or awakening to void three to four times per night. A maximum 40 percent rating is warranted when there is a daytime voiding interval less than one hour, or awakening to void five or more times per night. Id. Obstructed voiding manifested by obstructive symptomatology with or without stricture disease requiring dilatation 1 to 2 times per year warrants the assignment of a noncompensable rating. A 10 percent rating is warranted when there is marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: 1. Post void residuals greater than 150 cc; 2. Uroflowmetry; markedly diminished peak flow rate (less than 10 cc/sec); 3. Recurrent urinary tract infections secondary to obstruction; and/or 4. Stricture disease requiring periodic dilatation every 2 to 3 months. 38 C.F.R. § 4.115a. A maximum 30 percent rating is warranted for obstructed voiding manifested by urinary retention requiring intermittent or continuous catheterization. Id. Although the Board finds that the reduction from a 100 percent rating was proper, the Board finds that a rating of 10 percent for residuals of prostate cancer was warranted from April 1, 2006. The medical evidence of record dated closest to the reduction includes an April 2007 VA treatment record which noted that the Veteran had some incontinence and diarrhea after prostate cancer, requiring Loperamide. In a statement dated in July 2007, the Veteran stated that during the past 6 to 8 months his urine voids had been getting progressively worse. He stated that he had to resort to using Depends, not knowing when urine would leak and wet his clothes. He also noted he had diarrhea leakage and that he changed his Depends up to 3 times daily. He stated that his sleep was disrupted by 3 to 4 trips to the bathroom. He stated that his urinary stream is either weak or disrupted resulting in more time spent in the bathroom. An April 2008 VA treatment record did not note that the Veteran had urinary urgency or urinary hesitancy. Incontinence was noted. A June 2008 VA treatment record noted that the Veteran had a history of prostate cancer with some incontinence and diarrhea afterward requiring loperamide. The Veteran is service-connected for diarrhea, as a residual of adenocarcinoma of the prostate, from April 1, 2006. The VA treatment records indicate that the Veteran had a history of prostate cancer, but did not have active prostate cancer. A January 2009 VA treatment record reflected that the Veteran had no urinary or bowel complaints. June 2009, January 2010 and July 2010 VA treatment records noted that the Veteran had no dysuria/hematuria/no retention and no increased frequency. An April 2009 VA treatment record noted that the Veteran was informed that his January 2009 lab results were normal. A January 2010 VA treatment record noted that the Veteran had blood in his urine. A July 2010 VA treatment record noted that urinalysis and prostate tests were normal. At the June 2010 Board hearing, when asked whether he had any residuals from the prostate cancer treatment, he stated that he had severe diarrhea. See Tr. at 4. He also stated that he had problems with leakage and that he had to urinate approximately 8 times a day. He stated that he had erectile dysfunction. Id. The Veteran stated that he wore pads that he changed five to seven times a day. Tr. at 5. He stated that he got up four to six times a night to go to the bathroom. He also reported pain when he was trying to urinate. Id. At a September 2010 VA examination, the Veteran reported urinary daytime frequency of 6 times per day and nighttime frequency of 2 to 3 times per night. He was positive for urinary hesitancy and urinary urgency. He had a weak urinary stream. He was positive for dysuria and had periodic bladder incontinence. He changed protective undergarments 3 times per day. He denied having urinary tract infections. The Veteran reported that he has to pre-plan outings to make allowance for bowel and bladder incontinence/urgency. The examiner found that the Veteran had "erectile dysfunction, urinary frequency/urgency and periodic urinary incontinence; he has bowel urgency with periodic bowel incontinence as a residual of the treatment for the prostate cancer." As a lay person, the Veteran is competent to report symptoms capable of lay observation, such as urinary frequency. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In the July 2007 statement, the Veteran stated that during the past 6 to 8 months, he wore Depends which he changed up to 3 times daily. He stated that his sleep was disrupted by 3 to 4 trips to the bathroom. The Veteran's testimony at the Board hearing indicate he changed pads five to seven times a day and got up four to six times a night to go to the bathroom. The September 2010 VA examination report indicated the Veteran had nighttime frequency of 2 to 3 times per night and changed protective undergarments 3 times per day. Although the April 2007 VA treatment record noted that the Veteran had some incontinence and diarrhea following prostate cancer, the Veteran's statements regarding the frequency of his needing to change pads and voiding frequency are not entirely consistent with the VA treatment records. The January 2009 VA treatment record reflected that the Veteran had no urinary or bowel complaints. June 2009, January 2010 and July 2010 VA treatment records noted that the Veteran had no dysuria/hematuria/no retention and no increased frequency. However, the Veteran has consistently report the symptoms of voiding frequency and pad changes during the period on appeal and he did not have a VA examination until September 2010. Consequently, giving the Veteran the benefit of the doubt, the Board finds that a higher rating is warranted for the Veteran's residuals of prostate cancer from April 1, 2006. The July 2007 statement indicated that the Veteran changed Depends pads up to 3 times daily. His testimony at the June 2010 hearing indicated that he changed pads five to seven times a day. The September 2010 VA examination report indicated the Veteran changed protective undergarments 3 times per day. Given the fact that the VA treatment records consistently indicate the Veteran did not have urinary complaints, the Board finds that the evidence is most consistent with a finding that he changed his protective undergarments three times per day, as he reported in the July 2007 statement and at the September 2010 VA examination. Under the Diagnostic Code for voiding dysfunction, the wearing of absorbent material which must be changed 2 to 4 times per day warrants a 40 percent rating. Thus, the Board finds that the criteria for a 40 percent rating, but no higher, are met, from April 1, 2006. The Board has considered whether a higher rating is warranted under any other diagnostic code. The Veteran has also reported symptoms of diarrhea and erectile dysfunction, however, he is separately rated for those disabilities. The Board has considered whether extraschedular consideration is warranted based on the evidence of functional, including occupational, impairment secondary to the left knee disability. See Barringer v. Peake, 22 Vet. App. 242 (2008). The discussion above reflects that the symptoms of the Veteran's residuals of prostate cancer are contemplated by the applicable rating criteria. The competent medical evidence of record shows that the residuals of prostate cancer are primarily manifested by voiding dysfunction and urinary frequency. The diagnostic codes used to rate the Veteran's disability provide for ratings based on these symptoms. The effects of the Veteran's disabilities have been fully considered and are contemplated in the rating schedule. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). In sum, the Board finds that the reduction of the Veteran's rating for acdenocarcinoma of the prostate from 100 percent. The Board further finds that a rating of 40 percent, but no higher, is warranted from April 1, 2006, for residuals of prostate cancer. II. Diarrhea The Veteran has asserted that he is entitled to a higher rating for diarrhea. For the reasons that follow, the Board finds that a higher rating of 30 percent is warranted. Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the appellant. Id. § 4.3. An appeal from the initial assignment of a disability rating, such as the appeal in this case, requires consideration of the entire time period involved, and contemplates staged ratings where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected diarrhea is currently evaluated as 10 percent disabling under Diagnostic Code 7399-7319, and is thus rated by analogy under the criteria for irritable colon syndrome. See 38 C.F.R. §§ 4.20, 4.114, Diagnostic Code 7319. Under DC 7319, for irritable colon syndrome (spastic colitis, mucous colitis, etc.), mild irritable colon syndrome, with disturbances of bowel function with occasional episodes of abdominal distress, is rated as noncompensable (0 percent) disabling. Moderate irritable colon syndrome, with frequent episodes of bowel disturbance with abdominal distress, is rated 10 percent disabling. Severe irritable colon syndrome, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, is rated as 30 percent disabling. 38 C.F.R. § 4.114, DC 7319. In the July 2007 rating decision, the RO granted entitlement to service connection for diarrhea due to radiation treatment for adenocarcinoma of the prostate effective April 1, 2006. Thus, the period on appeal is from April 1, 2006. In a January 2006 VA treatment record, the Veteran reported that he had intermittent diarrhea since X-ray therapy for prostate cancer. A May 2006 VA treatment record also noted that the Veteran had intermittent diarrhea. An April 2007 VA treatment record noted that the Veteran had a history of prostate cancer with some incontinence and diarrhea afterward requiring Loperamide. In a July 2007 statement, the Veteran reported that diarrhea leakage had ruined countless pairs of clothing. He stated that he changed his Depends up to 3 times daily. A July 2007 VA treatment record noted that the Veteran stated that he was having accidents in public. A November 2007 letter from the Veteran's physician noted that the Veteran was on two medications that could be causing the diarrhea. He was instructed to stop taking the Metaformin to see if the diarrhea improved. A December 2007 VA nurse telephone note stated that the Veteran reported that he still had diarrhea after stopping the metformin and he was going to start his metformin again and stop the omeprazole to see if this would help with diarrhea. An April 2008 VA treatment record indicated that the Veteran reported having had mostly chronic diarrhea, but if he took Loperamide, he had diarrhea alternating with constipation. He had no bright red blood per rectum, fever, or abdominal pain. Another April 2008 VA treatment record noted that the Veteran had incontinence, but did not note that the Veteran had diarrhea. A January 2009 VA treatment record noted that the Veteran had "no urinary or bowel complaints." The record noted that Veteran had no abnormal pain/constipation, diarrhea. In a January 2009 statement submitted to VA, the Veteran stated that he had problems with his diarrhea, which was had not gotten any better, since September 2004. He reported that he wore pads provided by VA and before that was buying his own at his own expense. A February 2009 VA treatment record reflected that the Veteran was prescribed Loratadine for diarrhea or loose stools. A June 2009 VA treatment record noted that the Veteran had "no abnormal pain/constipation, diarrhea." At the June 2010 hearing, the Veteran stated that he had severe diarrhea since his treatment for prostate cancer. See June 2010 Board Hearing Transcript (Tr.) at p. 4. He reported that he wore pads and changed them five to seven times a day. See Tr. at p. 5. When asked if he had any abdominal distress, the Veteran indicated he had a cramp almost constantly in the lower part of his stomach, and "I don't know if it's gas or diarrhea or whatever it may be." Tr. at p. 8. He described his diarrhea as severe. Tr. at p. 9. The Veteran also stated that he had weakness and fatigue. Id. A July 2010 VA treatment record noted that the Veteran had "no abnormal pain/constipation, diarrhea." At the September 2010 VA examination, the Veteran reported that he had 4 to 5 loose/watery stools per day. The Veteran reported having periodic incontinence. He stated that he changed protective undergarments three times per day. The report noted that the Veteran had to pre-plan outings so he knew where bathrooms were located in order to make allowances for bowel and bladder incontinence/urgency. On examination, there were no anal fissures, fistulas, ulcerations or hemorrhoids. Digital rectal examination of rectal walls and prostate was without abnormalities. The VA examiner stated that the Veteran had bowel urgency with periodic bowel incontinence as a residuals of the treatment for the prostate cancer. He was not housebound or bedridden. He was able to leave home unaccompanied at his discretion. The VA examiner noted that the Veteran reportedly had not been able to work with the aforementioned urinary and bowel disabilities. A December 2010 VA treatment record indicated that the Veteran had an elective outpatient colonoscopy. Indications for the procedure were heme-positive stool and colonic polyps. The impression was hemorrhoids, internal without complication, colonic polyp, radiation colitis and diverticular of the colon. A January 2011 VA treatment record noted that the Veteran had a benign polyp. A September 2011 VA treatment record noted that the Veteran had no abdominal pain/constipation, diarrhea. Based on the evidence of record, the Board finds that the Veteran is not entitled to a higher evaluation for diarrhea under Diagnostic Code 7319. As noted above, under Diagnostic Code 7319, irritable colon syndrome, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, is rated as 30 percent disabling. 38 C.F.R. § 4.114, DC 7319. The Board finds that the evidence of record is against a finding that the Veteran was in constant abdominal distress. The January 2006 and May 2006 VA treatment records noted the Veteran had intermittent diarrhea. The April 2007 VA treatment record indicated the Veteran had "some" diarrhea. The Veteran reported having "no urinary or bowel complaints" in January 2009. The June 2009, July 2010, and September 2011 VA treatment records indicated that the Veteran had "no abnormal pain/constipation, diarrhea." The Veteran has asserted that he has severe diarrhea. In the July 2007 statement, the Veteran reported that diarrhea leakage had ruined countless pairs of clothing and he changed his Depends up to 3 times daily. At the September 2010 VA examination, he reported that he had 4 to 5 loose/watery stools per day and periodic incontinence. At the June 2010 hearing, he reported having severe diarrhea and having a cramp "almost constantly." The Veteran is competent to report symptoms capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). While the Board finds the Veteran's statements to be generally credible, some of his reported symptoms are inconsistent with his VA treatment records. The July 2010 VA treatment record, dated one month after the hearing, indicated that the Veteran had "no abdominal pain/constipation, diarrhea." At the September 2010 VA examination, a few months later, he reported having 4 to 5 loose/watery stools per day. As noted above, in contrast to the Veteran's statements, VA treatment records from January 2009, June 2009, July 2010, and September 2011 reflected that the Veteran had "no abdominal pain/constipation, diarrhea." As the Veteran consistently denied having abdominal pain in his VA treatment records, the Board finds the Veteran's assertion at the hearing that he had almost constant abdominal distress to be less than credible. The September 2010 VA examiner did not indicate that the Veteran had abdominal distress. On examination, the abdomen was non-tender and non-distended. The Board finds that the Veteran does not have symptoms of severe diarrhea, or alternating diarrhea and constipation with more or less constant abdominal distress, which would warrant a higher rating under Diagnostic Code 7139. The Board also considered whether the Veteran is entitled to a higher rating for his diarrhea under another Diagnostic Code. Under Diagnostic Code 7332 impairment of sphincter control of the rectum and anus with occasional involuntary bowel movements, necessitating wearing of pad warrants a 30 percent evaluation. Under Diagnostic Code 7332, constant slight, or occasional moderate leakage warrants a 10 percent rating. The Veteran has reported having leakage. Based on this evidence, the Board finds that the Veteran is entitled to a rating of 30 percent under Diagnostic Code 7332 for impairment of sphincter control with occasional involuntary bowel movements. The April 2007 VA treatment record indicated that the Veteran had incontinence and diarrhea. In the July 2007 statement, the Veteran reported that diarrhea leakage had ruined clothing and he changed his Depends up to 3 times daily. The July 2007 VA treatment record noted that the Veteran stated he was having accidents in public. As the Veteran's statements are consistent with the VA treatment records, the Board finds them to be credible. As the statements indicate the Veteran had occasional involuntary bowel movements necessitating wearing of pads, the Board finds that a higher rating of 30 percent for the Veteran's diarrhea is warranted. The Board has considered whether extraschedular consideration is warranted based on the evidence of functional, including occupational, impairment secondary to the service-connected diarrhea. See Barringer v. Peake, 22 Vet. App. 242 (2008). The discussion above reflects that the symptoms of the Veteran's diarrhea are contemplated by the applicable rating criteria. The competent medical evidence of record shows that the left knee disability is primarily manifested by frequent episodes of bowel disturbance with abdominal distress and incontinence. The applicable diagnostic codes used to rate the Veteran's disability provide for ratings based on these symptoms. The effects of the Veteran's disabilities have been fully considered and are contemplated in the rating schedule. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). In sum, the Board finds that a higher evaluation of 30 percent, but no higher, is warranted for the Veteran's diarrhea. ORDER The reduction of the Veteran's disability rating for adenocarcinoma of the prostate from 100 percent, effective April 1, 2006, was proper. Entitlement to an evaluation of 40 percent, but no higher, for residuals of adenocarcinoma of the prostate is granted, effective April 1, 2006. Entitlement to a disability evaluation of 30 percent for diarrhea is granted. REMAND TDIU is an element of all appeals for an increased evaluation. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the evidence of record indicates the Veteran's service-connected disabilities have affected his ability to work. The September 2010 VA examination report noted that the Veteran stated that as a result of the diabetes mellitus, hypertension and the residuals of the prostate cancer, he is not able "to do a good day's work." The examiner stated that the Veteran had not been able to work with the aforementioned urinary and bowel disabilities. The Veteran is service-connected for diabetes mellitus. As the evidence indicates the Veteran may be unemployable due to his service-connected disabilities, the issue of entitlement to a TDIU has been raised by the record and the claim must be remanded for adjudication of the claim. As the Veteran has several disabilities, including non-service disabilities, which may affect his ability to work, a VA examination is necessary. The September 2010 VA examination report indicates that the Veteran is receiving Social Security Administration disability for arthritis of his neck and lower back. As the records may be relevant to the claim for entitlement to TDIU, an attempt should be made to obtain the records. The Veteran's most recent VA treatment records were printed in November 2011. Consequently, the Board requests the Veteran's complete VA treatment records from November 2011 to present. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a letter notifying him of any information or lay or medical evidence not previously provided that is necessary to substantiate the TDIU claim on appeal, either on a schedular or extra-schedular basis. Provide the Veteran with a VA Form 21-8940, Veteran's Application for Increased Compensation Based Upon Unemployability, and ask him to complete the form in its entirety. 2. Obtain all of the Veteran's VA treatment records from November 2011 to present. If no records are available, the claims folder must indicate this fact. 3. Request the Veteran's Social Security Administration records. If no records are available, the claims folder must indicate this fact. 4. After completion of the above and after any records obtained have been associated with the claims file, schedule the Veteran for a VA examination to assess the combined impairment resulting from his service-connected disabilities, including diabetes mellitus, residuals of adenocarcinoma of the prostate, diarrhea, left lower extremity peripheral neuropathy, right lower extremity peripheral neuropathy, and erectile dysfunction. All indicated tests and studies are to be performed. Prior to the examination, the claims folder and a copy of this remand should be forwarded to the examiner for review of the case. Following the examination, the examiner is requested to provide an opinion describing the combined effect of the service-connected disorders on the Veteran's ability to engage in substantially gainful employment. This opinion should include a statement as to whether it is as likely as not (50 percent or greater probability) that the Veteran was unable to secure or follow a substantially gainful occupation as a result of all of his service-connected disabilities. Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to any impairment caused by non-service-connected disabilities. The examiner is requested to provide a complete rationale for any opinion expressed. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit should an opinion to be made A complete rationale should be given for all opinion and conclusions expressed. 5. Thereafter, readjudicate the issue on appeal of entitlement to a TDIU. If any benefit sought is not granted, issue a supplemental statement of the case and afford the Veteran an appropriate opportunity to respond. The case should then be returned to the Board, as warranted. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs