Citation Nr: 1331357 Decision Date: 09/27/13 Archive Date: 10/01/13 DOCKET NO. 09-26 862 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE 1. Entitlement to service connection for the loss of use of a creative organ. 2. Entitlement to special monthly compensation based on the loss of use of a creative organ. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran served on active duty from June 1974 to December 1974. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a January 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Board remanded the case for further development in December 2010, July 2012, and February 2013. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a Court or Board remand confers upon the appellant the right to compliance with that order). The remands directed the Appeals Management Center to afford the Veteran an examination to determine whether the Veteran had any current residuals of the in-service surgeries to correct a congenital urethral stricture and to obtain a medical opinion as to the etiology of the claimed loss of use of a creative organ, erectile dysfunction, and infertility. The Veteran was provided with a VA examination in April 2013 and an additional VA medical opinion was obtained in August 2013. As the requested development has been completed to the extent possible, no further action to ensure compliance with the remand directives is required. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). The Board may thus proceed with adjudication of this appeal. In evaluating this case, the Board has not only reviewed the Veteran's physical claims file, but has also reviewed the Veteran's file on the "Virtual VA" system to ensure a complete assessment of the evidence. FINDINGS OF FACT 1. The loss of use of a creative organ manifested by erectile dysfunction and infertility is not shown to have manifested during service or for many years thereafter and is not related to disease or other event of active service or to a disability that was incurred in service. 2. The evidence of record shows that examination of the testes and penis is normal and there is no loss of one or both testes or penis deformity. 3. The erectile dysfunction is due to polysubstance abuse. CONCLUSIONS OF LAW 1. The criteria for service connection for loss of use of creative organ manifested by erectile dysfunction and infertility are not met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). 2. The criteria for special monthly compensation based on the loss of use of a creative organ have not been met. 38 U.S.C.A. §§ 1114(k), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.350(a) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by VCAA, VA has a duty 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 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ), in this case the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in September 2008 that fully addressed all three notice elements and was sent prior to the initial AOJ decision in this matter. Additional VCAA notice letters were sent to the Veteran in December 2010 and July 2012. The letters informed the Veteran of what evidence was required to substantiate the claims and of the Veteran's and VA's respective duties for obtaining evidence. In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Notice consistent with the Court's holding in Dingess was provided in September 2008. VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing a medical examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the service treatment records and VA treatment records dated from 2008 to 2009. The Veteran indicated in September 2008 that he had no additional information or evidence to submit. He did not identify any treatment for the claimed loss of use of a creative organ and the VA treatment records of record do not show any treatment for this claimed disorder. The Veteran was afforded VA medical examinations in March 2012, August 2012, and August 2013 in order to obtain medical evidence in support of his claims. A VA medical addendum opinion was obtained in August 2013. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the examination and opinion obtained are adequate. The examiner obtained a history from the Veteran, examined him, and reviewed the available pertinent records prior to rendering a medical opinion as to whether the Veteran has loss of use of a creative organ that is related to service. The Board finds that an additional medical examination is not necessary. The record does not otherwise indicate any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claims. 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); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Legal Authority Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The claimed disability is not listed as a chronic disease under 38 C.F.R. § 3.309(a) and the provisions of 38 C.F.R. § 3.303(b) are not applicable. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection requires competent evidence showing, (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be 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) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a veteran 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). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.102, 4.3, 4.7. Special monthly compensation is a statutory award in addition to awards based on the schedular evaluations provided by the diagnostic codes in the VA Rating Schedule. Claims for special monthly compensation, other than those pertaining to one-time awards and an annual clothing allowance, are governed by 38 U.S.C.A. § 1114(k)-(s) (West 2002), and 38 C.F.R. §§ 3.350, 3.352 (2013). Special monthly compensation is payable at a specified rate if the Veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organ. 38 U.S.C.A. § 1114(k), 38 C.F.R. § 3.350(a). Loss of a creative organ will be shown by acquired absence of one or both testicles (other than undescended testicles) or ovaries or other creative organ. Loss of use of one testicle will be established when examination by a board finds that: (a) The diameters of the affected testicle are reduced to one-third of the corresponding diameters of the paired normal testicle, or (b) The diameters of the affected testicle are reduced to one-half or less of the corresponding normal testicle and there is alteration of consistency so that the affected testicle is considerably harder or softer than the corresponding normal testicle; or (c) If neither of the conditions (a) or (b) is met, when a biopsy, recommended by a board including a genitourologist and accepted by the veteran, establishes the absence of spermatozoa. When loss or loss of use of a creative organ resulted from wounds or other trauma sustained in service, or resulted from operations in service for the relief of other conditions, the creative organ becoming incidentally involved, the benefit may be granted. 38 C.F.R. § 3.350(a)(1)(i-ii). Once the evidence has been assembled, it is the Board's responsibility to evaluate the evidence. 38 U.S.C.A. § 7104(a). The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.102, 4.3. Discussion In the present case, the Veteran asserts that he has loss of use of his creative organ and he is sterile and unable to have children due to the urethral surgery in service. He contends that service connection for loss of use of a creative organ is warranted. The Board finds that the weight of the lay and medical evidence demonstrates that the loss of use of a creative organ manifested by erectile dysfunction and infertility is not caused by any in-service event or injury and is not related to service. The more probative evidence of record, specifically the 2013 VA medical opinions and the service treatment records establish that the loss of use of a creative organ manifested by erectile dysfunction and infertility did not first manifest in service and is not medically related to service. There is competent evidence that the Veteran has loss of use of a creative organ manifested by erectile dysfunction. The April 2013 VA examination report shows a diagnosis of erectile dysfunction. In addition, the Veteran asserts that he has infertility. The August 2013 VA medical opinion notes that the examiner indicated that it was unclear whether the Veteran had infertility and a fertility work up with sperm counts would need to be done by a fertility specialist. See the April 2013 VA examination report and the August 2013 VA addendum opinion. The examiner did address the question of whether the claimed infertility was related to service, to include the inservice treatment for urethral stricture. Service treatment records do not show any complaints, findings or diagnosis of erectile dysfunction, loss of use of a creative organ, or infertility. A March 2012 VA examination report notes that the examiner indicated that review of the service treatment records did not show any discussion of erectile dysfunction or any other sexual issues. Service treatment records show that in July 1974, the Veteran sought treatment due to an inability to void. He was ultimately hospitalized, and he underwent a suprapubic cystotomy. The bladder was severely trabeculated and thickened, revealing a long-standing lower tract obstruction. Multiple attempts at passing the catheter were unsuccessful. Finally, a catheter was brought up through the penis, and a suprapubic Malecot catheter was placed. The suprapubic tube was removed four days postoperatively, and the catheter was also later removed as well. The Veteran was then able to void. The diagnosis was of a congenital urethral stricture. Three specific operations were performed: a suprapubic cystotomy, antegrade passage of a catheter, and an internal urethrotomy. Later, while still in service, the Veteran voiced some complaints regarding voiding irregularities, and further treatment was provided. Service treatment records do not document that the Veteran underwent prostate surgery or an orchiectomy in service. Service connection is not in effect for any disabilities. Service connection for urethral stricture and removal of the bladder was denied in a Board decision in December 2010. The Board found that the urethral stricture was a congenital or developmental defect and such defects were not considered to be diseases or injuries within the meaning of applicable legislation concerning service connection. The Board found that the competent evidence did not reflect any aggravation of the congenital condition in service. Service connection for removal of half of a bladder was also denied by the Board in the December 2010 decision. The Board indicated that the Veteran's bladder was certainly implicated in the suprapubic cystotomy he underwent in service. The Board found that the service treatment records did not reflect the removal of half the bladder or, indeed, any part of the bladder. The Board found that the evidence did not show that the disability of which the Veteran complained existed and service connection for removal of half the bladder was denied. Service connection is not in effect for any disabilities. The Veteran now asserts that the loss of use of a creative organ manifested by erectile dysfunction and infertility were caused by the urethral strictures and surgery in service. The record shows that the loss of use of the creative organ first manifested well over three decades after service separation in December 1974. The record shows that the Veteran first reported having loss of use of a creative organ when he filed his claim for VA compensation benefits in August 2008. In September 2008, the Veteran was afforded an initial vesting examination at a VA facility. He reported his 1974 in-service surgery, which he characterized as a "prostate surgery." He indicated that the surgery was for urinary obstruction, the cause of which was unknown to him. The Veteran indicated that he had done well since the surgery until three months earlier when he started straining, experiencing urgency, and suffering from a degree of incontinence. He also complained of genital discomfort in the location of the surgery. He reported having erectile dysfunction, loss of use of a creative organ, and infertility due to the surgery in service. The Veteran reported having loss of use of a creative organ upon VA examination in November 2008. A September 2009 VA treatment record indicates that the Veteran reported that he was unable to perform sexually and he was sterile. He reported having a prostatectomy and orchiectomy. The Board finds that the weight of the competent and credible evidence demonstrates that the loss of use of a creative organ manifested by erectile dysfunction and infertility is not caused by any in-service event or injury, to include the surgery in service and is not related to service. The more probative evidence of record, specifically the 2013 VA medical opinions and the service treatment records establish that the loss of use of a creative organ manifested by erectile dysfunction and infertility did not first manifest in service and is not medically related to service, but is caused by poly substance abuse. The weight of the competent and credible evidence establishes that the loss of use of a creative organ manifested by erectile dysfunction and infertility is not caused by the urethral strictures or the surgery in service. The Veteran was afforded a VA examination in April 2013. The Veteran reported that he has had problems obtaining an erection for a long time. He stated that he had this problem for 4 or 5 years when he first started having problems with depression. The Veteran reported that he had his testicle removed and replaced in service and a part of his prostate was taken out. He stated that this is when all the problems started. Physical examination revealed that the Veteran did not have an orchiectomy. He did not have a history of chronic epididymitis, epididymo-orchitis, or prostatitis. Physical examination of the penis, testes, and epididymis was normal. The examiner opined that it was less likely than not that the loss of use of a creative organ manifested by erectile dysfunction and infertility were proximately due to or the result of the urethral stricture in service. The examiner noted that the National Institute of Health states that "a urethral (u-REE-thrul) stricture occurs when scarring narrows the urethra - the tube that carries urine out of your body. A stricture restricts the flow of urine from the bladder and can cause a variety of medical problems in the urinary tract, including inflammation or infection." The examiner noted that these conditions are treated with catherization, urethroplasy, endoscopic internal urethrotomy, dilation, or implanted stent or permanent catheter. The examiner stated that these treatments do not cause or lead to impotence. In the August 2013 VA addendum opinion, the VA examiner stated that he reviewed the Veteran claims folder in connection with the VA examination. The examiner noted that the Veteran had a congenital urethral stricture and his urinary bladder and the urethra were scoped during urological procedures to dilate the urethra. The examiner indicated that although these procedures were no doubt traumatic for the Veteran at the time, none of these procedures can lead to erectile dysfunction, loss of use of a creative organ, or infertility. The examiner opined that it was less likely than not that any of the Veteran's current creative organ complaints were caused by or had an onset in the military service. The examiner noted that the Mayo Clinic as well as other reputable publications list substance abuse such as cocaine as the cause of infertility, erectile dysfunction, and impotence and this Veteran had a long history of cocaine and marijuana abuse. The examiner stated that he was certain that the Veteran had no procedures in service that would have caused infertility or erectile dysfunction. The examiner further stated that as with most men his age, he had benign prostatic hypertrophy for which he was currently prescribed medications, and this was not likely the cause of infertility as he developed benign prostatic hypertrophy (BPH) later in his life. The examiner stated that the Veteran's years of poly substance abuse is more likely the cause of his erectile dysfunction, impotence, and infertility, if he had infertility. The examiner noted that a fertility workup with sperm counts was needed to be done by a fertility specialist however, even that work up would be inconclusive as to the cause of why he has no children. The Board finds the 2013 VA medical opinion to have great evidentiary weight as the opinion reflects a comprehensive and reasoned review of the entire evidentiary record. The VA examiner reviewed the claims folder including the service treatment records and the Veteran's medical history, considered the Veteran's own reported medical history, and examined the Veteran before rendering the medical opinion. The VA examiner specifically addressed the treatment and surgery for urethral strictures in service and discussed the examination findings generated at the time of service and at the time of the current examination. The examiner provided a rationale for his conclusion, pointed to the medical evidence which supported his conclusion and cited to medical research as well. Factors for assessing the probative value of a medical opinion are the examiner's access to the claims file and the thoroughness and detail of the opinion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The medical opinion is based on sufficient facts and data. In Nieves-Rodriguez, 22 Vet. App. 295, the Court held that guiding factors in evaluating the probity of a medical opinion are whether the opinion was based on sufficient facts or data, whether the opinion was the product of reliable principles and methods, and whether the medical professional applied the principles and methods reliably to the facts of the case. For these reasons, the Board has assigned great probative weight to the VA medical opinion and finds that it outweighs the statements of the Veteran. The Board finds that the 2013 VA medical opinion, the service treatment records, and the post service evidence establish that the Veteran's loss of use of a creative organ first manifested many years after service separation and is not related to active service. There is medical evidence of record which supports the conclusion that the treatment and surgery for urethral strictures in service did not cause the current loss of use of the creative organ. A March 2012 VA examination report indicates that the examiner opined that it was highly unlikely that a urethral stricture would cause erectile dysfunction and the erectile dysfunction was more than likely due to an enlarged prostate. The November 2008 VA examination report shows that the examiner opined that the urethral strictures were a congenital disorder that existed prior to service and were not aggravated during service beyond the natural progression of the disease. The examiner emphasized that the Veteran was asymptomatic for many years following service. There is competent evidence which establishes that the Veteran's prostate symptoms and disorder are not related to his active service or the urethral stricture surgery in service. The more competent and credible evidence establishes that the Veteran did not have prostate surgery or an orchiectomy in service. In the August 2013 VA medical opinion, the examiner stated that the Veteran developed benign prostate hypertrophy later in life. The February 2011 VA examination report indicates that the examiner opined that the Veteran's prostate hyperplasia was not related to the urethral strictures that were discovered and treated while the Veteran was on active service. The August 2012 VA examination report indicates that the examiner reviewed the claims folder and indicated that the Veteran did not have an orchiectomy or prostatectomy during or after military service. Examination of the penis revealed that the penis was uncircumcised. Examination of the testes, epididymis, and prostate was normal. The examiner stated that the Veteran did not have a penile deformity, a history of testis removal, or a prostatectomy. The Veteran himself contends that he was sterile and impotent as a result of the congenital urethral stricture. He reported an inability to obtain an erection at all currently. The Veteran has attempted to relate the loss of use of a creative organ to the treatment and surgery for urethral strictures in service. The Veteran, as a lay person, is competent to describe observable symptoms such as pain and firsthand events such as an inability to obtain an erection. Although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, as to the specific issue in this case, an opinion as to the etiology of erectile dysfunction or infertility falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4 (lay persons not competent to diagnose cancer). Some medical issues require specialized training for a determination as to diagnosis and causation; therefore such issues are not susceptible of lay opinions on etiology. Lay testimony on the question of relating the current loss of use of the creative organ is not competent in the present case because the Veteran is not competent to state that this disorder is related to incident or event in service. See Davidson v. Shinseki, 581 F.3d 1313, 316 (Fed. Cir. 2009); Kahana (lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent). A diagnosis of infertility requires clinical or diagnostic testing and these tests are not found within the record during or immediately following his service period. Additionally, an opinion of etiology would require knowledge of the complexities of the genitor-urinary system and the various causes of erectile dysfunction and infertility and it is not shown that the Veteran has this knowledge. The Board finds that the weight of the competent and credible evidence establishes that the loss of use of a creative organ manifested by erectile dysfunction and infertility did not manifest in service, but first manifested over 30 years after service separation. The loss of use of a creative organ is not medically related to injury or other incident of active service and is caused by poly substance abuse. For the reasons and bases discussed above, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for the loss of use of a creative organ manifested by erectile dysfunction and infertility, 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. § 3.102. Special Monthly Compensation After careful review of the record, the Board finds that special monthly compensation is not warranted based on loss of use of a creative organ. In this regard, service connection is not in effect for any disabilities. As discussed above, there is no competent evidence to establish that the urethral stricture surgery in service or any other event or incident in service caused loss of use of the creative organ. The evidence of record shows that examination of the testes is normal and there is no competent evidence of loss of one or both testes, infertility, or loss of use of a creative organ due to wounds or trauma in service or operations or surgery in service. See the VA examination reports dated in November 2008, February 2011, March 2012, August 2012, April 2013, and August 2013. Thus, the Board finds that the competent evidence establishes that special monthly compensation for loss of use of a creative organ is not warranted. The Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. (CONTINUED ON NEXT PAGE) ORDER Service connection for loss of use of a creative organ manifested by erectile dysfunction and infertility is denied. Entitlement to special monthly compensation due to loss of use of a creative organ is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs