Citation Nr: 1335653 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 10-23 975 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for a genitourinary disability, to include inguinal lymphadenopathy, swollen lymph nodes, urinary tract infections, dysuria, and frequency, including as due to cold weather injury. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD E. Pomeranz, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from July 1956 to June 1958. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2009 rating action by the Department of Veterans Affairs (VA) Regional Office (RO) located in Columbia, South Carolina. In June 2012, the Board remanded this case for the purpose of affording the Veteran a hearing before a Veterans Law Judge (VLJ). In October 2012, the Veteran and his wife testified via videoconference before the undersigned VLJ, seated at the Board's Central Office in Washington, D.C. A transcript of the hearing has been associated with the claims file. In December 2012 and June 2013, the Board remanded this case for additional development. The purposes of these remands have been met and the case is ready for appellate consideration. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT There is a preponderance of the evidence against a nexus between a current diagnosis of a genitourinary disability, to include obstructive uropathy, inguinal lymphadenopathy, swollen lymph nodes, urinary tract infections, dysuria, and frequency, and any incident of service, to include cold weather injury. CONCLUSION OF LAW Service connection for a genitourinary disability, to include obstructive uropathy, inguinal lymphadenopathy, swollen lymph nodes, urinary tract infections, dysuria, and frequency, including as due to cold weather injury, is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1116, 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA enhanced VA's duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The VCAA also redefined the obligations of VA with respect to the duty to assist the veteran with the claim. Id. In the instant case, the Board finds that VA fulfilled its duties to the Veteran under the VCAA. Duty to Notify VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. The Board concludes that the letter dated in December 2008 that was sent to the Veteran adequately apprised him of the information and evidence needed to substantiate the claim. The RO thus complied with VCAA's notification requirements. In order to meet the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must: (1) inform the claimant about the information and evidence 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. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Additionally, on March 3, 2006, the United States Court of Appeals for Veterans' Claims (Court) issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484, 486 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Board finds that VA has met these duties with regard to the claim adjudicated on the merits in this decision. There is no issue as to providing an appropriate application form or completeness of the application. Written notice provided in December 2008 fulfills the provisions of 38 U.S.C.A. § 5103(a). That is, the Veteran received notice of the evidence needed to substantiate his claim, the avenues by which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. See Beverly, 19 Vet. App. at 394, 403; see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005) (Mayfield I) rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In addition, the December 2008 letter also informed the Veteran about how VA determines effective dates and disability ratings, as required by Dingess. The Board also recognizes that, according to Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004), proper VCAA notice must "precede an initial unfavorable [agency of original jurisdiction (AOJ)] decision on a service-connection claim." VA did provide such notice to the Veteran prior to the July 2009 decision that is the subject of this appeal in its December 2008 letter. With respect to the Dingess requirements, the Veteran was provided with notice of what type of information and evidence was needed to substantiate the claim, as well as the type of evidence necessary to establish a rating or effective date of an award (see letter from RO, dated in December 2008), and such notice was provided prior to the initial decision of the RO. See Dingess, supra. Accordingly, the RO provided proper VCAA notice at the required time. The Veteran has been provided the opportunity to respond to VA correspondence and over the course of the appeal has had multiple opportunities to submit and identify evidence. Furthermore, he has been provided a meaningful opportunity to participate effectively in the processing of his claim by VA. Duty to Assist VA also has a duty to assist the veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence. In this regard, according to the National Personnel Records Center (NPRC), the Veteran's service treatment records are not available and were presumably destroyed in the 1973 fire at the NPRC. Thus, further efforts to obtain these records would be futile. See 38 U.S.C.A. § 5103A(b)(3); 38 C.F.R. § 3.159(c)(2). The Veteran has, however, submitted morning reports that indicate that he was hospitalized due to a foot infection in May and June 1957. The Board notes substantial compliance with the remand directives in its previous remands in December 2012 and June 2013, to the extent possible. See Stegall v. West, 11 Vet. App. 268 (1998). In the December 2012 remand, the Board noted that according to the Veteran, he was hospitalized during service after developing a foot infection due to cold and wet feet. The Veteran maintained that as a result of his foot infection, he developed inguinal lymphadenopathy with swollen lymph nodes and that such led to his current genitourinary disability, characterized by symptoms to include frequency, dysuria, and urinary tract infections. The Board noted that it remained unclear as to whether the Veteran had any genitourinary disability characterized by the aforementioned symptoms, and if so, what was the etiology thereof. Thus, the Board directed the RO to afford the Veteran a VA examination in order to determine whether the Veteran had a current genitourinary disability, and, if so, whether it had its clinical onset during active service or was related to any in-service disease, event, or injury, specifically to include the Veteran's foot infection in May and June 1957 which resulted in swollen lymph nodes in the groin area, and/or any exposure to cold during service. In March 2013, the Veteran underwent a VA examination. At that time, the examiner opined that it was less likely than not that the Veteran had any genitourinary disability that was related to his period of service, to include in-service exposure to cold weather. He reported that the Veteran had polyuria and urinary tract infections, but that he did not know of any relationship between cold weather injuries and polyuria and urinary tract infections. In June 2013, the Board once again remanded this case. The Board stated that the examiner from the March 2013 VA examination did not comment on the Veteran's lay assertions that his infection spread to the lymph nodes in his groin, causing them to swell, and that he had experienced frequent urination and urinary tract infections since that time. Thus, the Board concluded that the opinion was inadequate. The Board directed that the Veteran's claims file be forwarded to the examiner who conducted the March 2013 VA examination for an addendum opinion. If the same examiner was not available, a different examiner was to be asked to review the claims file and provide the requested opinion. Specifically, the examiner was directed to determine whether the Veteran had a current genitourinary disability, and, if so, whether it had its clinical onset during active service or was related to any in-service disease, event, or injury, specifically to include the Veteran's foot infection in May and June 1957 which resulted in swollen lymph nodes in the groin area, and/or any exposure to cold during service. In June 2013, a VA examiner, different from the examiner who conducted the March 2013 VA examination, provided the addendum opinion. The examiner recognized that during service, the Veteran developed a foot infection which likely caused him to develop swollen lymphadenopathy in his groin. The examiner also reported that the Veteran experienced dysuria, urinary frequency, and urinary tract infections. However, the examiner indicated that given the Veteran's age of 79 and history of benign prostatic hyperplasis, it was more likely that it was obstructive uropathy that was contributing to the increased urinary tract infection as opposed to the remote history of the foot injury. Thus, the examiner opined that the Veteran's genitourinary issues were not connected to his foot injury in 1957. In light of the above, the Board finds that the RO has complied with the instructions from the Board's December 2012 and June 2013 remands. The RO provided the Veteran with a VA examination as directed, and also obtained an addendum opinion. The examination report and addendum opinion substantially comply with the Board's remand directives as they are responsive to the questions posed by the Board. Stegall v. West, 11 Vet. App. 268 (1998). The examiner from the addendum opinion specifically provided findings in sufficient detail and provided a rationale for his findings. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Therefore, the examination in this case, with addendum opinion, are adequate upon which to base a decision. The Board finds that the medical evidence of record is sufficient to resolve this appeal, and the VA has no further duty to provide an examination or opinion. 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2013); 38 C.F.R. § 3.159(c)(4) (2013). See also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran was afforded a videoconference hearing before the undersigned VLJ in October 2012, in which he presented oral argument. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, the undersigned VLJ set forth the issue to be discussed at the hearing and sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. The VLJ notified that Veteran that in order to prove his claim he had to show that he currently had a genitourinary disability that was related to his period of active service, to include in-service cold weather injury. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the Board hearing. The hearing focused on the elements necessary to substantiate the claim and the Veteran, through his testimony, demonstrated that he had actual knowledge of those elements. As such, the Board finds that consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claim based on the current record Based on the foregoing, it is the Board's determination that the VA fulfilled its VCAA duties to notify and to assist the Veteran, and thus, no additional assistance or notification was required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard, supra. II. Pertinent Laws and Regulations Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the Federal Circuit Court held that a three-element test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a relevant disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a)-benefit from a somewhat more relaxed evidentiary standard. See Walker, supra (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. Thus, if the claimant does not have one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and "medical nexus of a relationship [sic] between the condition in service and the present condition is required." Walker, supra. (holding that the claimant's allegation of a continuity of hearing loss ever since active service was not sufficient to support the claim under subsection 3.303(b), as hearing loss was not among the chronic diseases listed in section 3.309(a)). The condition at issue in this case, a genitourinary disability, currently diagnosed as obstructive uropathy, is not a "chronic disease" listed under 38 C.F.R. § 3.309(a). Therefore, 38 C.F.R. § 3.303(b) does not apply and, as such, the Veteran is not permitted to show continuity of symptomatology since his service as an alternative means of etiologically linking the aforementioned disability to his military service. See Walker, supra. Lay evidence nonetheless 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). Lay persons can also provide an eye-witness account of an individual's visible symptoms. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a veteran seeks benefits and the evidence is in relative equipoise, the veteran prevails. See Gilbert, 1 Vet. App. at 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). III. Factual Background As previously stated, the Veteran's service treatment records are not available and are presumed destroyed in a fire at the NPRC in 1973. The Veteran has, however, submitted morning reports that indicate that he was hospitalized due to a foot infection in May and June 1957. In a private medical statement from A.J.B., M.D., dated in October 2008, Dr. B. stated that the Veteran experienced urinary symptoms of frequency and dysuria since being treated in the military for inguinal lymphadenopathy. According to Dr. B., those symptoms had not changed since discharge. In December 2008, the Veteran filed a claim for entitlement to service connection for a genitourinary disability, specifically inguinal lymphadenopathy. He stated that while he was stationed in Germany, he was treated for swollen lymph nodes in his groin area. In a second private medical statement from Dr. A.J.B., dated in October 2011, Dr. B. stated that she had been the Veteran's primary care physician since March 2000. Since then, he had been treated for urinary symptoms including frequency, urinary tract infections, and dysuria. She also noted that she had read articles related to cold injuries. Dr. B. opined that it was more likely than not that the Veteran's "current residuals of exposure to cold injury [were] related to his military service." In December 2012, the Board remanded this case. The Board noted that during the course of the appeal, the Veteran had asserted that he was exposed to cold during service, while sleeping in fox holes, and that his feet were cold and wet. He noted that due to the cold and wet feet, he was hospitalized for a serious foot infection. The Veteran maintained that as a result of his foot infection, he developed inguinal lymphadenopathy with swollen lymph nodes and that such led to his current genitourinary disability, characterized by symptoms to include frequency, dysuria, and urinary tract infections. The Board noted that it remained unclear as to whether the Veteran had any genitourinary disability characterized by the aforementioned symptoms, and if so, what was the etiology thereof. Thus, the Board directed the RO to afford the Veteran a VA examination in order to determine whether he had a current genitourinary disability, and, if so, whether it had its clinical onset during active service or was related to any in-service disease, event, or injury, specifically to include the Veteran's foot infection in May and June 1957 which resulted in swollen lymph nodes in the groin area, and/or any exposure to cold during service. The examiner had to consider the Veteran's lay statements regarding his in-service hospitalization for a foot infection and exposure to cold while sleeping in fox holes, and his statements that he observed dark urine and bedwetting on occasion, as well as his lay statements of continuous symptoms after service. Specifically, the examiner had to consider the Veteran's assertions that during service, he slept in foxholes and had cold and wet feet, was subsequently treated for a foot infection, and that during his hospitalization for the foot infection, he developed inguinal lymphadenopathy with swollen lymph nodes that resulted in his current genitourinary disability. In March 2013, the Veteran underwent a VA examination. At that time, the examiner stated that he had reviewed the Veteran's claims file. The examiner opined that it was less likely than not that the Veteran had any genitourinary disability that was related to his period of service, to include in-service exposure to cold weather. He stated that the Veteran had frequency that was unchanged since the 1957 incident of foot infection. The Veteran admitted that it had not worsened or improved since that time. According to the examiner, medically, he could not explain why the Veteran would have frequency related to that foot infection. There were many reasons for polyuria (uncontrolled diabetes, diabetes insipidus, primary polydipsia, and neurogenic bladder) which should be considered. The examiner noted that he would blame the Veteran's enlarged prostate but that the Veteran assured him that the symptoms started prior to the benign prostatic hypertrophy (BPH) and had been unchanged since his diagnosis of BPH. There were no other in-service diseases, injuries, or events to explain the polyuria or remote urinary tract infections. The examiner indicated that he did not know of any relationship between cold weather injuries and polyuria and urinary tract infections. In June 2013, the Board once again remanded this case. The Board stated that the examiner from the March 2013 VA examination did not comment on the Veteran's lay assertions that his infection spread to the lymph nodes in his groin, causing them to swell, and that he had experienced frequent urination and urinary tract infections since that time. Thus, the Board concluded that the opinion was inadequate. The Board directed that the Veteran's claims file be forwarded to the examiner who conducted the March 2013 VA examination for an addendum opinion. If the same examiner was not available, a different examiner was to be asked to review the claims file and provide the requested opinion. Specifically, the examiner was directed to determine whether the Veteran had a current genitourinary disability, and, if so, whether it had its clinical onset during active service or was related to any in-service disease, event, or injury, specifically to include the Veteran's foot infection in May and June 1957 which resulted in swollen lymph nodes in the groin area, and/or any exposure to cold during service. In June 2013, a VA examiner, different from the examiner who conducted the March 2013 VA examination, provided the addendum opinion. The examiner recognized that during service, the Veteran had a cold foot injury in 1957 with inguinal lymphadenopathy. The Veteran was concerned that his previously diagnosed inguinal lymphadenopathy was contributing to his frequent urinary tract infections, frequency, and dysuria. The examiner noted that the Veteran had some dark urine. The examiner opined that the dark urine was likely some rhabdomyolysis from the foot injury. According to the examiner, the Veteran's renal function had not been permanently impaired due to the rhabdomyolysis. The examiner further opined that the swollen lymphadenopathy in the Veteran's groin was likely secondary to the foot infection and not due to any genitourinary issues. The examiner reported that the Veteran experienced dysuria, urinary frequency, and urinary tract infections. The examiner indicated that given the Veteran's age of 79 and history of benign prostatic hyperplasis, it was more likely that it was obstructive uropathy that was contributing to the increased urinary tract infection as opposed to the remote history of the foot injury. Thus, the examiner opined that the Veteran's genitourinary issues were not connected to his foot injury in 1957. In a subsequent addendum, dated in September 2013, the examiner who provided the June 2013 addendum opinion stated that he had reviewed the Veteran's claims file. IV. Analysis The Veteran's service treatment are not obtainable, and it is presumed that they were destroyed in a fire at the NPRC in 1973. As such, there is a heightened obligation to explain findings and to carefully consider the benefit of the doubt rule in cases such as this. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). However, case law does not establish a heightened "benefit of the doubt," only a heightened duty of the Board to consider the applicability of the benefit of the doubt, to assist the claimant in developing a claim, and to explain its decision when the veteran's medical records have been lost. See Ussery v. Brown, 8 Vet. App. 64 (1995). Similarly, case law does not lower the legal standard for proving a claim for service connection, but rather increases the Board's obligation to evaluate and discuss in its decision all the evidence that may be favorable to the veteran. See Russo v. Brown, 9 Vet. App. 46 (1996). Based on a thorough review of the record, the Board finds that there is a preponderance of evidence against the Veteran's claim for service connection for a genitourinary disability, to include obstructive uropathy, inguinal lymphadenopathy, swollen lymph nodes, urinary tract infections, dysuria, and frequency, including as due to cold weather injury. In this regard, the Veteran contends that he was hospitalized during service after developing a foot infection due to cold and wet feet. The Veteran maintains that as a result of his foot infection, he developed inguinal lymphadenopathy with swollen lymph nodes and that such led to his current genitourinary disability, characterized by symptoms to include frequency, dysuria, and urinary tract infections. Although the Veteran's service treatment records are not available, the Veteran has submitted morning reports that indicate that he was hospitalized due to a foot infection in May and June 1957. In addition, the Veteran is competent to report that he was exposed to cold during service. See Washington v. Nicholson, 19 Vet. App. 362 (2005) (holding that a veteran is competent to report what occurred during service because he is competent to testify as to factual matters of which he has first-hand knowledge.) He is also competent to report that he developed swollen lymph nodes in the groin area. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that lay testimony is competent to establish the presence of observable symptomatology); see also Jandreau, supra; Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). The Board further notes that in the June 2013 VA addendum opinion, the examiner characterized the Veteran's in-service swollen lymph nodes as swollen lymphadenopathy in the Veteran's groin. The examiner also opined that such was likely secondary to the Veteran's foot infection. Thus, the Board accepts as true that during service, the Veteran was exposed to cold and developed a foot infection which caused him to develop lymphadenopathy and swollen lymph nodes in the groin area. However, the pertinent question in this case is whether the Veteran currently has a genitourinary disability that is related to his period of service, to include his cold and foot injuries and swollen lymph nodes in the groin. In this case, there is no evidence of record showing that the Veteran currently has lymphadenopathy with swollen lymph nodes in the groin area. Rather, the Veteran's currently diagnosed genitourinary disability is obstructive uropathy which was diagnosed by the VA examiner in the June 2013 addendum opinion. The VA examiner also opined that given that the Veteran's age was 79 and he had a history of benign prostatic hyperplasis, it was the Veteran's obstructive uropathy that was contributing to his urinary problems, such as urinary tract infections, as opposed to the remote history of the in-service foot injury. Thus, because the examiner did not link the Veteran's currently diagnosed obstructive uropathy to his period of service, to include his cold and foot injuries and swollen lymph nodes in the groin, this opinion opposes, rather than supports, the Veteran's claim. The Board attaches significant probative value to this conclusion reached by the VA examiner in June 2013. The opinion was clearly based on a review of the claims file with specific citation to the clinical record. The opinion was also supported by a rationale. Thus, the probative value of the June 2013 VA opinion is high as the examiner was fully informed of the Veteran's medical history, he provided a fully articulated rationale, and the opinion was supported by a reasoned analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-04 (2008); see Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion. . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."]. In this case, the Board recognizes that the Veteran has complaints of urinary tract infections, dysuria, and frequency. However, service connection is not available for symptoms. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (symptoms alone, without a diagnosed or identifiable underlying malady or condition, do not in and of themselves constitute a disability for which service connection may be granted). The aforementioned symptoms reported by the Veteran are not disabilities in and of themselves. Id. Because these urinary symptoms do not constitute independent disabilities, service connection cannot be granted for them. The Board also notes that although the Veteran is competent to describe his urinary symptoms (see Jandreau, supra), he is not competent to give an opinion as to whether he has an underlying genitourinary disability manifested by such urinary symptoms that is related to his period of service, to include his in-service cold and foot injuries and swollen lymph nodes in the groin, as these issues involve highly complex medical questions concerning an internal physical process. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009). Determining the etiology of complex medical conditions requires medical training and would not be subject to lay observation, as contrasted with the situations contemplated by Jandreau and Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of varicose veins). Absent such credentials, the Veteran is unable to provide a competent opinion as to any underlying genitourinary disability or as to medical causation. Thus, the Veteran's lay opinion that he has a genitourinary disability manifested by urinary tract infections, dysuria, and frequency, that is related to his period of service, to include his in-service cold and foot injuries and swollen lymph nodes in the groin, is not competent evidence and cannot be considered as evidence favorable to his claim. The first evidence of record of a diagnosed genitourinary disability, specifically obstructive uropathy, was in June 2013, approximately 55 years after the Veteran's discharge. With respect to negative evidence, the Court has held that the fact that there was no record of any complaint, let alone treatment, involving the veteran's condition for many years could be decisive. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000), [it was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints]; see also Forshey v. Principi, 284 F.3d 1335 (Fed. Cir. 2002) ["negative evidence" could be considered in weighing the evidence]. The pertinet question in this case is whether the Veteran's genitourinary disability, currently diagnosed as obstructive uropathy, is related to his period of service, specifically his in-service foot infection and/or cold weather injury and/or swollen lymph nodes in the groin. In support of his claim the Veteran submitted private medical statements from Dr. A.J.B., dated in October 2008 and October 2011. In the statements, Dr. B. noted that the Veteran had experienced urinary symptoms, including frequency, urinary tract infections, and dysuria, since service. She also opined that it was more likely than not that the Veteran's "current residuals of exposure to cold injury [were] related to his military service." To the extent that Dr. B.'s opinion is offered to show that the Veteran currently has a genitourinary disability manifested by frequency, urinary tract infections, and dysuria, that is related to his period of service, specifically to his in-service cold injury, the Board does not afford this opinion any weight. First, the Board notes that Dr. B. does not provide an actual diagnosis of any genitourinary disability; she only refers to urinary symptoms, such as frequency, urinary tract infections, and dysuria, without providing an underlying diagnosis. Because these urinary symptoms do not constitute independent disabilities, service connection cannot be granted for them. Second, even if Dr. B. had provided a diagnosis of a genitourinary disability, it appears that the rationale for her opinion is that the Veteran had experienced urinary symptoms since service. However, as previously stated, a genitourinary disability is not a "chronic disease" and, as such, the Veteran is not permitted to show continuity of symptomatology since service as an alternative means of etiologically linking a genitourinary disability to his military service. Therefore, the Board does not afford Dr. B.'s opinion any weight. The Board also recognizes that in the March 2013 VA examination report, the examiner opined that it was less likely than not that the Veteran had a genitourinary disability that was related to his period of service, to include in-service exposure to cold weather. However, given that this opinion was considered to be inadequate by the Board in a June 2013 remand, the Board does not afford this evidence any weight. In sum, the Board finds the detailed opinion from the VA examiner in the June 2013 addendum opinion substantially outweighs the private medical statements from Dr. B. and the lay statements from the Veteran. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection a genitourinary disability, to include obstructive uropathy, inguinal lymphadenopathy, swollen lymph nodes, urinary tract infections, dysuria, and frequency, including as due to cold weather injury, and it therefore must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a genitourinary disability, to include obstructive uropathy, inguinal lymphadenopathy, swollen lymph nodes, urinary tract infections, dysuria, and frequency, including as due to cold weather injury, is denied. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs