Citation Nr: 1328863 Decision Date: 09/10/13 Archive Date: 09/17/13 DOCKET NO. 12-05 512 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to an initial disability rating for prostate cancer, status post radical retropubic prostatectomy with residual scar, bladder neck contracture, and post radiation cystitis (hereinafter "residuals of prostate cancer"), in excess of 20 percent prior to January 12, 2010, and in excess of 40 percent for the period from January 12, 2010. 2. Entitlement to an initial disability rating (evaluation) in excess of 0 percent for erectile dysfunction. ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, the appellant in this case, had active military service from July 1969 to June 1972. This appeal comes to the Board of Veterans' Appeals (Board) from November 2009 and February 2012 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. In reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. For the rating period prior to January 12, 2010, the Veteran's residuals of prostate cancer were manifested by a urinary retention disorder requiring the need to awaken to void three to four times per night. 2. For the rating period prior to January 12, 2010, the Veteran's residuals of prostate cancer were not manifested by a urinary retention disorder requiring intermittent or continuous catheterization, the wearing of absorbent materials which must be changed two to four times per day, a daytime voiding interval between two and three hours, or awakening to void five or more times per night. 3. For the rating period from January 12, 2010, the Veteran's residuals of prostate cancer were manifested by a urinary retention disorder requiring the use of absorbent materials which must be changed two to four times a day. 4. For the rating period from January 12, 2010, the Veteran's residuals of prostate cancer were not manifested by a urinary retention disorder requiring the use of absorbent materials which must be changed more than four times a day. 5. The Veteran's erectile dysfunction is not productive of deformity of the penis. CONCLUSIONS OF LAW 1. For the period prior to January 12, 2010, the criteria for a higher initial disability rating in excess of 20 percent for residuals of prostate cancer have not been met or more nearly approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.115a, 4.115b, Diagnostic Code 7528 (2012). 2. For the period from January 2010, the criteria for a higher initial disability rating in excess of 40 percent for residuals of prostate cancer have not been met or more nearly approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.115a, 4.115b, Diagnostic Code 7528 (2012). 3. The criteria for a compensable evaluation for erectile dysfunction have not been met for any period. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.31, 4.115b, Diagnostic Code 7522 (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). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). After having carefully reviewed the record on appeal, the Board has concluded that the notice requirements of VCAA have been satisfied with respect to the initial rating issue decided herein. The RO sent the Veteran a letter in September 2009 that informed him of the requirements needed to establish service connection for prostate cancer due to Agent Orange exposure, including information regarding the assignment of ratings and effective dates. As this case concerns an initial rating and comes before the Board on appeal from the decision which also granted service connection, there can be no prejudice to the Veteran from any alleged failure to give adequate 38 U.S.C.A. § 5103(a) notice for the service connection claim. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice arises from receipt of a notice of disagreement). VA satisfied its duty to assist the Veteran in the development of the claim. First, VA satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file includes the Veteran's private treatment records, VA examination report, an American Cancer Society article titled "Detailed Guide: Prostate Cancer," and lay statements. Additionally, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the issue that has not been obtained. Thus, the Board concludes that VA has made every reasonable effort to obtain all records relevant to the Veteran's appeal. Second, VA satisfied its duty to obtain a medical opinion when required. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume that the examination report and opinion are adequate and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Indeed, even when the adequacy is challenged, the Board may assume the competency of any VA medical examiner, including even nurse practitioners, as long as, under 38 C.F.R. § 3.159(a)(1), the examiner is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). Here, the Veteran was provided with a VA genitourinary examination (the report of which has been associated with the claims file) in October 2009. In his April 2010 Notice of Disagreement, the Veteran stated that the October 2009 examiner conducted only a verbal examination with no physical examination except to listen to his heart, take his blood pressure, and measure his surgery scar. However, while the Veteran has made a statement with regard to the content of the VA examination, he has not challenged, in his Notice of Disagreement or elsewhere in the record, the adequacy of the examination, examiner, or opinion provided. The Board finds the VA examination was thorough and adequate for rating purposes. The VA examiner personally interviewed and examined the Veteran, fully reviewed all medical evidence of record, made specific findings indicating the nature of the Veteran's claimed disabilities, and addressed the relevant criteria in the applicable diagnostic codes. While there has been some indication of worsening of the Veteran's service-connected residuals of prostate cancer since the examination was conducted, this has been taken into account by the staged rating assigned for this disability, as discussed below. As such, the Board finds the examination report adequate to adjudicate the Veteran's claim for higher initial ratings for residuals of prostate cancer and erectile dysfunction and no further examination is necessary. The Veteran was offered the opportunity to testify at a hearing before the Board, but declined. As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Disability Rating Laws and Regulations Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4 (2012). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Where, as here, the question for consideration is the propriety of the initial evaluations assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of staged ratings is required whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Pyramiding, that is, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14 (2012). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Initial Rating for Residuals of Prostate Cancer The Veteran is service connected for residuals of prostate cancer, initially rated as 20 percent disabling for the rating period prior to January 12, 2010 and 40 percent disability for the rating period from January 12, 2010. The Veteran contends that he experiences nocturia, i.e., awakening to void, three to four times per a night. In his April 2010 Notice of Disagreement, the Veteran stated that, while he was not wearing any absorbent pads at the time of the October 2009 VA examination, he has subsequently had to start wearing two absorbent pads per day. He also stated that a January 2010 CT scan of his bladder showed a thickening of the wall of the bladder. Having reviewed the evidence of record, the Board finds that the criteria for an initial rating greater than 20 percent for the rating period prior to January 12, 2010 and great than 40 percent for the rating period from January 12, 2010 for the Veteran's service-connected residuals of prostate cancer have not been met or more nearly approximated. The adenocarcinoma of the prostate has been evaluated under 38 C.F.R. § 4.115b, Diagnostic Code (DC) 7528, the criteria used for malignant neoplasms of the genitourinary system. Under DC 7528, following the cessation of surgical, X-ray, antineoplastic chemotherapy, or another therapeutic procedure, a rating of 100 percent shall be assigned and shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e) (2012). If there has been no local recurrence or metastasis, the evaluation is to be based upon residuals as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115b. Pursuant to the provisions of DC 7527, postoperative residuals of prostate gland injuries are evaluated under voiding dysfunction, renal dysfunction or urinary tract infection, whichever is predominant. 38 C.F.R. § 4.115b. 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 DC 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 though, the Veteran has not alleged and the evidence does not show that his residuals of prostate cancer are associated with or have been accompanied by albuminuria, edema, hypertension, or decrease in kidney function. 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. The criteria for a compensable rating of 20 percent for urinary leakage are the wearing of absorbent materials, which must be changed less than two times per day. A 40 percent rating is warranted for urinary leakage requiring the use of absorbent materials which must be changed two to four times a day. A 60 percent rating is warranted for urinary leakage requiring the use of absorbent materials which must be changed more than four times a day. Id. In addition, urinary frequency encompasses ratings ranging from 10 to 40 percent. A 20 percent rating contemplates a daytime voiding interval between one and two hours, or awakening to void three to four times per night. A 40 percent rating contemplates a daytime voiding interval of less than one hour, or awakening to void five or more times per night. Id. A 30 percent rating is contemplated for urinary retention requiring intermittent or continuous catheterization. Id. There are no criteria for a rating higher than 30 percent under the obstructed voiding criteria. As stated above, the Veteran contends that he is entitled to a higher initial rating for the residuals of prostate cancer. In connection with his appeal, the Veteran submitted private treatment records spanning a period from May 2005 through September 2011. August 2009 private treatment records note that the Veteran experienced nocturia two to three times per night, but that he denied urinary hesitancy or weak stream. The Veteran underwent a VA examination in October 2009. The Veteran reported that his urinary flow was once every two hours during the day with nocturia two times per a night. The Veteran denied any incontinence and stated he did not wear absorbent material of any type. The Veteran reported normal control of the urinary bladder, but would occasionally have some slight leakage with bending or lifting. A January 12, 2010 private treatment record notes the Veteran had some worsening of urinary incontinence and urinary frequency with stress urinary incontinence requiring one to two small pads per day. A January 19, 2010 private treatment record noted thickening of the bladder wall. February and March 2010 private treatment records also noted the Veteran experienced stress incontinence requiring one to two small pads per a day. In his April 2010 Notice of Disagreement, the Veteran stated that he awakened to void three to four times per night. He indicated that, while he was not wearing any absorbent material the time of the October 2009 VA examination, he has since needed to use absorbent pads two times per day, noting the January 12, 2010 appointment with his private doctor for his bladder issues. May and September 2010 as well as March and September 2011 private treatment records continued to note the Veteran stress incontinence that required the use of two pads per day. Having reviewed the evidence of record, the Board finds that, for the period prior to January 12, 2010, the criteria for an initial rating in excess of 20 percent for the service-connected residuals of prostate cancer have not been met or more nearly approximated. The evidence does not show that the Veteran's residuals of prostate cancer are associated with or have been accompanied by a urinary retention disorder requiring intermittent or continuous catheterization. While the October 2009 VA examination report does note that the Veteran used a catheter, the report goes on to indicate that the Veteran has normal control of the urinary bladder, indicating that such notation was in error. The Veteran has not alleged at any time during the appeal period that he requires the use of intermittent or continuous catheterization for his urinary retention disorder. As such, a disability rating in excess of 20 percent for the period prior to January 12, 2010 is not warranted under the criteria for obstructed voiding. 38 C.F.R. § 4.115a. The evidence of record demonstrates that the Veteran's residuals of prostate cancer for the period prior to January 12, 2010 did not require the wearing of absorbent materials that must be changed two to four times per day. At the October 2009 VA examination, the Veteran stated he occasionally experienced some slight urinary leakage upon bending or lifting. The examination report notes that the Veteran did not wear any absorbent material at all of any type. In his April 2010 Notice of Disagreement, the Veteran acknowledged that he was not using absorbent pads of any kind at the October 2009 VA examination. He stated he had required absorbent pads subsequent to the VA examination, but did not mention the frequency at which pads had to be changed or when he first began wearing absorbent pads, and specifically referenced his January 12, 2010 private treatment for bladder issues. Additionally, there is no mention in the Veteran's private treatment records of the Veteran requiring the use of absorbent materials prior to the January 12, 2010 record. As such, the evidence does not indicate that the Veteran changed absorbent materials two to four times per a day during the period prior to January 12, 2010. Thus, a disability rating in excess of 20 percent is not warranted under the criteria for voiding dysfunction. Id. Finally, the evidence of record does not show, and the Veteran has not alleged, that the Veteran experienced daytime voiding in intervals less than one hour or that he awakened to void five or more times per night. The October 2009 VA examination report noted daytime urinary intervals of two hours. The Veteran's private treatment records, dating during the period prior to January 12, 2010, do not contain any evidence that the Veteran experienced daytime voiding in intervals of less than one hour. An August 2009 private treatment record noted that the Veteran experienced nocturia two to three times per night. The Veteran, in his April 2010 Notice of Disagreement, stated that he had nocturia three to four times per night. However, the Veteran has not stated, in his Notice of Disagreement or elsewhere in the record, that he awakened to void five or more times per night or that he had a daytime voiding interval of less than one hour, as required for a rating in excess of 20 percent for urinary frequency. Id. For these reasons, the Board finds that for the period prior to January 12, 2010 the symptomatology for the Veteran's residuals of prostate cancer do not more nearly approximate that required for an initial rating in excess of 20 percent under 38 C.F.R. § 4.115a. Having reviewed the evidence of record, the Board finds that, for the period from January 12, 2010, the criteria for a higher initial rating in excess of 40 percent for the service-connected residuals of prostate cancer have not been met or more nearly approximated. The earliest evidence of record that the Veteran's urinary incontinence required the use of absorbent materials that had to be changed two to four times per day was noted in a January 12, 2010 private treatment record. As noted above, subsequent private treatment records dated from January 2010 through September 2011 also noted the Veteran experienced urinary leakage requiring the use of absorbent pads two times per day. The Veteran has not stated, or even alleged, that his urinary incontinence requires the use of absorbent pads that must be changed more than four times per day and the private treatment records submitted by the Veteran do not support such a finding. For this reason for the period from January 12, 2010, the Board finds that the symptomatology for the Veteran's residuals of prostate cancer do not more nearly approximate that required for a higher initial rating in excess of 40 percent under 38 C.F.R. § 4.115a. The October 2009 VA examination report noted a well healed surgical scar, 18 cm long, 2 mm. wide, and slightly hypopigmented. The examiner noted no tenderness or adhesions associated with the scar. Under the criteria for rating skin disorders, a compensable rating for a scar requires a burn scar, an unstable or painful scar, or a scar that has other disabling effects. As the evidence does not reflect that the Veteran's prostate scar meets any of these criteria, the criteria for a to a separate compensable rating for this scar are not met. 38 C.F.R. § 4.118. The Veteran is also service connected for bladder neck contracture and cystitis. In the instant case, the Veteran's residuals of prostate cancer are rated as a voiding dysfunction. See 38 C.F.R. §§ 4.115a, 4.115b, DC 7528. The Veteran's bladder neck contracture and cystitis cannot be separately evaluated because to do so would be in violation of VA's rules against pyramiding. See 38 C.F.R. §§ 4.14, 4.115a, 4.115b, DC 7512, 7517. As stated above, in determining whether the Veteran is entitled to separate ratings for different problems or residuals of an injury such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of or overlapping with the symptomatology of the other condition(s). See Esteban, 6 Vet. App. at 261-62. A rating for bladder neck contracture and cystitis, status post radiation treatment itself, would violate the rule against pyramiding. As already noted, the Veteran's residuals of prostate cancer are rated as a voiding dysfunction, which constitutes the predominant symptomatology. The separately service-connected bladder neck contracture and cystitis are rated as injury to the bladder and chronic cystitis, respectfully, which are also to be rated as voiding dysfunctions. To rate each of these disorders relying on the same symptomatology of urinary frequency; nocturia three to four times a night; stress incontinence; and, the use of absorbent materials that must be changed two to four times per a day would violate the rule against pyramiding. Therefore, a compensable evaluation for these disorders cannot be awarded. For these reasons, the Board finds that a preponderance of the evidence is against the appeal for an initial rating for the Veteran's service-connected residuals of prostate cancer greater than 20 percent for the rating period prior to January 12, 2010 and great than 40 percent for the rating period from January 12, 2010; thus, the appeal must be denied. Because the preponderance of the evidence is against the appeal, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Initial Rating for Erectile Dysfunction The Veteran is service connected for erectile dysfunction, initially rated as 0 percent disabling. The Veteran contends that he is entitled to a higher (compensable) disability rating for the erectile dysfunction because penile deformity and erectile dysfunction should be treated as two separate issues. In his April 2010 Notice of Disagreement, the Veteran stated that his erectile dysfunction has created loss of intimacy issues between him and his spouse. He also submitted an article from the American Cancer Society regarding the effects of prostate cancer surgery. After a review of all the evidence, the Board finds that, for the entire rating period, a compensable evaluation is not warranted for erectile dysfunction. Erectile dysfunction is rated under DC 7522, which provides for a single 20 percent rating where the evidence shows deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b. There is no schedular rating for loss of erectile power alone. When the rating schedule does not provide a 0 percent evaluation for a DC, a 0 percent rating is assigned when the requirements for a compensable disability rating are not met. 38 C.F.R. § 4.31. Under DC 7522, the loss of erectile power without penis deformity does not warrant a compensable rating (aside from special monthly compensation which the Veteran is already receiving). See id. The Board finds that the evidence of record shows that there is no deformity of the penis. The private treatment records submitted by the Veteran, spanning a period from May 2005 through September 2011, do not indicate deformity of the penis. A March 2007 private treatment record noted that the Veteran stated he and his spouse had noticed some Peyronie's curvature of his penis for about three months. The private medical professional observed that he did not feel any specific plaque at the present time and that the Veteran's penis was normal. A January 2009 private treatment record noted that the Veteran's penis was normal and the meatus was adequate. Subsequent private treatment records dated through September 2009 continue to report the Veteran's penis as normal and do not reflect any further complaints from the Veteran regarding penile deformity. Additionally, the October 2009 VA examination diagnosed the Veteran with erectile dysfunction, but did not note any penile deformity. The Board has reviewed the Veterans lay statements regarding his erectile dysfunction as well as the American Cancer Society article titled "Detailed Guide: Prostate Cancer" that was submitted by the Veteran. While they do paint a picture of the difficulty his erectile dysfunction causes, these statements do not establish that a compensable schedular rating is warranted, because such a rating requires the occurrence of penile deformity with loss of erectile power. As described above, the evidence of record establishes that a compensable schedular rating is not warranted for the Veteran's erectile dysfunction at any time during the course of his appeal; therefore, staged ratings are not appropriate. Again, the Veteran is already in receipt of special monthly compensation under 38 U.S.C.A. § 1114(k) due to loss of use of a creative organ. Hence, his erectile dysfunction is already compensated. Additionally compensation requires evidence of a deformity of the penis itself, not merely loss of erectile power. For these reasons, the Board finds that a preponderance of the evidence is against the appeal for a compensable evaluation, in excess of 0 percent, for erectile dysfunction, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's residuals of prostate cancer is specifically contemplated by the schedular rating criteria. Prior to January 12, 2010, the Veteran's residuals of prostate cancer were manifested by a urinary retention disorder requiring the need to awaken to void three to four times per night. From January 12, 2010, the Veteran's residuals of prostate cancer have been manifested by a urinary retention disorder requiring the use of absorbent materials which must be changed two to four times a day. The rating criteria specifically contemplate such symptomatology. The schedular rating criteria specifically contemplate ratings based on frequency of urination and the use of absorbent materials. 38 C.F.R. § 4.115b, DC 7528. In this case, comparing the Veteran's disability level and the symptoms listed in the Rating Schedule, the degrees of disability throughout the entire period under consideration are contemplated by the Rating Schedule and the assigned ratings are, therefore, adequate. The Board also finds that the symptomatology and impairment caused by the Veteran's erectile dysfunction is specifically contemplated by the schedular rating criteria. For the entire rating period, the Veteran's erectile dysfunction has been characterized by the loss of erectile power. The rating criteria specifically contemplate such symptomatology. The schedular rating criteria specifically contemplate ratings based on penile deformity in connection with loss of erectile power. 38 C.F.R. § 4.115b, DC 7522. In this case, comparing the Veteran's disability level and the symptoms listed in the Rating Schedule, the degree of disability throughout the entire period under consideration is contemplated by the Rating Schedule and the assigned rating is, therefore, adequate. In the absence of exceptional factors associated with the Veteran's residuals of prostate cancer or erectile dysfunction, the Board finds that the criteria for submission for assignment for extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App at 218, 227 (1995). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is part of an increased rating claim when such claim is expressly raised by a veteran or reasonably raised by the record. In this case, the record does not reflect, and the Veteran does not allege, that he is unemployable due to the residuals of prostate cancer or erectile dysfunction. Rather, at the October 2009 VA examination, the Veteran indicated he owned a full time janitorial service and returned to work six months after his initial radiotherapy. He has not alleged that he is, or was at any time, unemployable on account his prostate cancer or erectile dysfunction. Thus, the Board finds that Rice is inapplicable because there is no evidence of unemployability due to the Veteran's service-connected residuals of prostate cancer or erectile dysfunction. ORDER An initial disability rating for prostate cancer, status post radical retropubic prostatectomy with residual scar, bladder neck contracture, and post radiation cystitis, in excess of 20 percent prior to January 12, 2010, and in excess of 40 percent for the period from January 12, 2010, is denied. An initial disability rating in excess of 0 percent for erectile dysfunction is denied. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs