Citation Nr: 1329065 Decision Date: 09/11/13 Archive Date: 09/17/13 DOCKET NO. 11-08 909 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUE Entitlement to service connection for urinary stress incontinence. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs ATTORNEY FOR THE BOARD Joseph Aquilina INTRODUCTION The Veteran served on active duty from March 1987 to February 1992. This case comes before the Board of Veteran's Appeals (the Board) on appeal from an August 2009 rating decision rendered by the Milwaukee, Wisconsin Regional Office (RO) of the Department of Veterans Affairs (VA). A review of the Veteran's online Virtual VA folder indicates that there is not relevant outstanding evidence pertinent to this claim. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran's claim for service connection for urinary stress incontinence was denied because the RO concluded that the urinary stress incontinence was not related to service. The RO premised this decision on the lack of in service treatment records related to urinary system. The Veteran states in her Notice of Disagreement that her urinary stress incontinence was caused by her two in-service pregnancies. The service treatment records do show in-service pregnancy. The Veteran also submitted a statement in June 2009 from a private physician, a gynecologist, opining that her disability was caused by her pregnancy. The opinion simply states that the Veteran "is under my professional care and to inform you that her stress incontinence was caused by her pregnancy." While the Veteran has pursued treatment for her diagnosed urinary stress incontinence, she was only referred to a VA physical therapist for treatment; she was not given a VA examination to assess urinary functioning nor has VA provided a medical opinion as to the absence or presence of a nexus of the disability to service. The May 2009 VA gynecological examination did not mention urinary incontinence, but that examination was conducted prior to the Veteran's claim leading to this appeal. A VA examination is warranted when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. Mclendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A (d) (2), 38 C.F.R. § 3.159(c) (4) (i). The third prong noted above, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McLendon v. Nicholson, 20 Vet. App. 79, at 83 (2006). In the instant case, the June 2009 statement for the private physician indicates symptoms of urinary incontinence that may be associated with pregnancy in-service. This opinion, however, is a bald statement without any rationale, and is insufficient on its own to provide a basis for awarding service-connection. Nonetheless, this examination is sufficient for the purpose of VA affording the Veteran a VA examination for the purpose of determining whether the Veteran's urinary symptoms are at least as likely as not related to service. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC shall obtain and associate with the claims file any additional VA medical records relevant to urinary symptoms and/or similarly relevant private medical records that the Veteran reasonably identifies. 2. The Veteran shall be afforded an appropriate VA genitourinary and/or gynecological examination determine the nature and etiology of the claimed urinary disability, claimed as urinary stress incontinence. All relevant symptomatology and observations shall be set forth. The claims file should be made available to the examiner and all medical records will be made available to the examiner prior to the rendering of any opinion regarding the claimed urinary incontinence disability. Based on the VA examination a review of the Veteran's statements and any previous etiologic statements made by prior examiners, the examiner shall offer and opinion as to the following question: Whether the Veteran has a urinary incontinence disability, and if so, whether it is at least as likely as not (at least a 50 percent probability) that any such disability or symptoms are related to the Veteran's active duty service, to include the in-service pregnancy and any associated complications. A complete rationale for all medical opinion must be provided. If the examiner cannot provide an opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would resort to speculation. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should provide a complete rationale for any opinion provided. 3. After completing the above actions and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim on appeal must be readjudicated. If any claim remains denied, a supplemental statement of the case must be provided to the Veteran and her representative. After the Veteran and her representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters 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). _________________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).