Citation Nr: 1334108 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 06-11 145A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected diabetes mellitus. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD M. Hudson, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1964 to June 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which denied the claim. The Veteran and his spouse testified before the undersigned Veterans Law Judge at a November 2011 hearing conducted via videoconference. A transcript of the hearing is of record. In March 2012, the Board remanded the case to the RO for additional evidentiary development. The Board finds there was substantial compliance with its remand order and that it may therefore proceed with a determination of the issue on appeal. See Stegall v. West, 11 Vet. App. 268 (1998). The Board's prior remand included a claim of service connection for peripheral neuropathy of the left arm, to include as secondary to service-connected diabetes mellitus. Service connection for peripheral neuropathy of the left arm was granted in an October 2012 rating decision; that issue is no longer before the Board. The issues of an increased rating for peripheral neuropathy of the left arm, an increased rating for degenerative arthritis of the right knee, an increased rating for arthritis of the right hip, an increased rating for residuals of a gunshot wound to the right knee, including damage to Muscle Group XIV, and a total rating for compensation based on individual unemployability (TDIU) have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. FINDING OF FACT A current disability of erectile dysfunction is shown, but a preponderance of the evidence fails to link the Veteran's erectile dysfunction to his military service, specifically his service-connected diabetes mellitus. CONCLUSION OF LAW The criteria for service connection for erectile dysfunction have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist 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). Appropriate notice was provided in March 2008 and June 2009 letters. The claim was subsequently readjudicated, most recently in an October 2012 supplemental statement of the case. Mayfield, 444 F.3d at 1333. As for the duty to assist, the Veteran's service treatment records (STRs), private medical treatment records and VA treatment records have been obtained. The Veteran has not claimed to be in receipt of disability benefits from the Social Security Administration. The Veteran has not identified, and the record does not otherwise indicate, any additional relevant medical records that have not been obtained and associated with his file. Two VA examinations have been secured in connection with the current claim for service connection. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300-01 (2008). Taken together, the Veteran's January 2009 and March 2012 VA examinations are sufficient as the VA examiners considered the entire record, noted the history of the disability, addressed relevant evidence, and provided explanations for the opinions stated as well as the medical information necessary to reach a decision. The Veteran claimed for the first time in a November 2012 letter that his erectile dysfunction could have been caused by any of his service-connected disabilities, not just his diabetes mellitus. However, the Board finds that a new VA examination is not warranted because other than the Veteran's own conclusory generalized lay statements, the evidence of record does not demonstrate that the claimed disability is related to the Veteran's additional service-connection conditions. By itself, the Veteran's statements are insufficient to warrant a new VA examination. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, VA's duty to assist with respect to obtaining VA examinations has been met. 38 C.F.R. § 3.159(c)(4). VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on his claims at this time. I. Service Connection The Veteran contends that service connection is warranted for his erectile dysfunction condition, to include as secondary to his service-connected diabetes mellitus. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service-connection on a secondary basis requires evidence sufficient to show that: (1) a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. See 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, the nexus between erectile dysfunction and diabetes mellitus, 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). Therefore, medical evidence will be required to address the question of whether the Veteran's service-connected diabetes mellitus caused his erectile dysfunction. In deciding whether service connection is warranted for a disability, 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 the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has thoroughly reviewed all the evidence in the Veteran's paper claims file and virtual record (including Virtual VA and Veteran's Benefits Management System (VBMS)). Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. 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, 128 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to a veteran). The Veteran contends that he has erectile dysfunction that is secondary to his service-connected diabetes mellitus. He has not contended that his erectile dysfunction is directly related to his service. In this regard, the Board observes that his STRs show no treatment for, or diagnosis of, erectile dysfunction. His discharge examination in June 1968 showed a clinically normal genitourinary system. According to post-service medical records, the Veteran was diagnosed with new onset diabetes in April 2006. See Dr. H. T., Progress Note, April 2006. The first mention in the medical records of the Veteran's erectile dysfunction is February 2008, when his private doctor stated that the Veteran's erectile dysfunction was secondary to his diabetes mellitus. See Dr. P. T., Doctor's Questionnaire, February 2008. No rationale for this opinion was provided. An August 2008 Cleveland VAMC note states that the Veteran has erectile dysfunction and is doing well on Viagra. See Cleveland VAMC, Primary Care Progress Note, August 2008. In January 2009, the Veteran was provided with a VA urology examination. The Veteran reported his erectile dysfunction began in 2006 or 2007. Since onset, the symptoms of his erectile dysfunction are inability to satisfactorily penetrate for intercourse. He has been treated with Viagra, with is sometimes effective. The diagnosis was erectile dysfunction. The VA examiner opined that the Veteran's "[e]rectile dysfunction is not caused by diabetes mellitus, as this would take longer to develop." July 2009 VAMC treatment records indicate that the Veteran was found to have hypogonadism in addition to erectile dysfunction. The doctor noted the Veteran was still taking Viagra, his testosterone levels were within normal limits and the testosterone levels would continue to be monitored. See Cleveland VAMC, Primary Care Progress Note, July 2009. Hypogonadism is a condition resulting from abnormally decreased gonadal function, with retardation of growth, sexual development, and secondary sex characters. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 902 (32nd. ed. 2012). During the Veteran's November 2011 Board videoconference hearing, he stated the VA claimed his hypogonadism was causing his erectile dysfunction. See Veteran's Hearing Transcript, pg. 31, November 2011. Pursuant to the Board remand, the Veteran was afforded a second VA urology examination in March 2012. The Veteran reported a decline in the quality of erections since 2003. The VA examiner found the Veteran was not able to achieve an erection sufficient for penetration and ejaculation with or without medication. The VA examiner noted the Veteran had a diagnosis of erectile dysfunction with an onset of 2003. The etiology was described as multifactorial. The examiner opined that it is less likely than not that the Veteran's erectile dysfunction is related to his diabetes or aggravated beyond normal progression by his diabetes. The rationale provided was that the Veteran reported having problems with erectile dysfunction as early as 2003, but he was not diagnosed with diabetes until 2006. Additionally, the Veteran's symptoms associated with his erectile dysfunction, only partial erections with medication, have been consistent since the onset of his condition. Based on a review of the evidence, the Board finds that service connection for erectile dysfunction is not warranted. Although the Veteran has been diagnosed with erectile dysfunction, the evidence does not show that it is related in any way to his service-connected diabetes. The January 2009 examiner opined that due to the Veteran's diagnosis of diabetes mellitus in April 2006 and the Veteran's reported onset of erectile dysfunction in 2006-2007, the Veteran's erectile dysfunction could not have been caused by his diabetes as the erectile dysfunction would have taken longer to develop. The March 2012 VA examiner found that the Veteran's diabetes did not cause his erectile dysfunction as the Veteran reported an onset of erectile dysfunction in 2003 but was not diagnosed with diabetes until April 2006. Additionally, the examiner opined that the Veteran's diabetes has not aggravated his erectile dysfunction beyond normal progression as the Veteran has had the same erectile dysfunction issues since onset, namely an ability to only achieve partial erections with medication. These two VA medical opinions are supported by detailed rationale. While there is one positive nexus opinion in the record from the Veteran's private physician, it is merely conclusory and provides no detailed rationale to support the finding that the Veteran's erectile dysfunction is secondary to his diabetes. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). Thus, the private physician's February 2008 opinion regarding the etiology of the Veteran's erectile dysfunction is of limited probative value. The Board acknowledges the Veteran and his wife's statements that his diabetes affected him prior to being diagnosed with the disorder. See Letter from Veteran, June 2011; see also Letter from Veteran's Wife, January 2011. However, no medical professional has provided such an opinion to that effect. Further, the evidence does not support a finding that the Veteran's service-connected diabetes aggravates his erectile dysfunction. The only medical opinion of record regarding this issue, that of the March 2012 VA examiner, indicates that the Veteran's erectile dysfunction is not aggravated by his diabetes. This opinion is uncontradicted. None of the Veteran's treatment records contain any opinion indicating that the Veteran's erectile dysfunction is aggravated by his diabetes mellitus. In this regard, the Board observes that the Veteran has not actually reported why he believes that his diabetes aggravates his erectile dysfunction. The Board acknowledges the Veteran's belief that his erectile dysfunction is related to his service-connected diabetes mellitus. However, there is no evidence of record showing that the Veteran has the specialized medical education, training, and experience necessary to render a competent medical opinion as to the etiology of this disability. See Kahana, 24 Vet. App. at 435. Thus, the Veteran's own assertions as to etiology of this disability have no probative value. Based on the lack of probative evidence of an association between the Veteran's erectile dysfunction and his service-connected diabetes mellitus, the Board concludes that the preponderance of the evidence is against the Veteran's claims for service connection for erectile dysfunction, including as due to his service-connected diabetes mellitus. The benefit-of-the-doubt rule does not apply and the benefit sought on appeal is accordingly denied. 38 U.S.C.A § 5107; Gilbert, 1 Vet. App. at 53-56. ORDER Entitlement to service connection for erectile dysfunction, including as secondary to the service-connected diabetes mellitus, is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs