Citation Nr: 1340281 Decision Date: 12/06/13 Archive Date: 12/20/13 DOCKET NO. 08-17 260 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana THE ISSUES 1. Whether new and material evidence has been received to reopen the claim of service connection for bilateral inguinal hernia, including secondary to service-connected chronic epididymitis. 2. Entitlement to an increase in the 10 percent evaluation currently assigned for chronic epididymitis. 3. Entitlement to special monthly compensation (SMC) for loss of use of a creative organ. 4. Entitlement to service connection for restless leg syndrome, claimed as secondary to service-connected chronic epididymitis. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Christopher Maynard, Counsel INTRODUCTION The Veteran had active service from January 1969 to July 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2006, September 2008, and August 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Offices (RO) in St. Louis, Missouri, and in New Orleans, Louisiana. In September 2006, the RO in St. Louis, Missouri denied an increased rating for chronic epididymitis. In September 2008, the RO found that new and material evidence had not been received to reopen the claim for bilateral inguinal hernia, including secondary to service-connected epididymitis, and denied entitlement to SMC based on loss of use of a creative organ. In August 2009, the RO in New Orleans, Louisiana denied service connection for restless leg syndrome. Although the RO found that new and material evidence had not been received to reopen the Veteran's claim for service connection for inguinal hernias, the Board must first decide whether new and material evidence has been received to reopen the Veteran's claim. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); McGinnis v. Brown, 4 Vet. App. 239, 244 (1993) (holding that Board reopening is unlawful when new and material evidence has not been submitted). The issue of service connection for restless leg syndrome is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Service connection for bilateral inguinal hernia, including secondary to service-connected epididymitis was last finally denied by the RO in June 2000. 2. The evidence received since the June 2000 RO decision is cumulative and redundant of evidence previously considered and does not raise a reasonable possibility of substantiating the claim of service connection for bilateral inguinal hernia. 3. The Veteran's epididymitis is manifested primarily by pain in the testicles, but does not require drainage, frequent hospitalizations more than two times a year or continuous intensive management; and does not cause poor renal function. 4. 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. CONCLUSIONS OF LAW 1. New and material evidence has not been received to reopen the claim of service connection for bilateral inguinal hernia, including secondary to service-connected epididymitis. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2013). 2. The schedular criteria for an evaluation in excess of 10 percent for chronic epididymitis are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.20, 4.115b, Part 4, including Diagnostic Codes 7599-7525 (2013). 3. 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 Before addressing the merits of the Veteran's claim, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2013). Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159. Such notice must indicate that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Id; 38 U.S.C.A. §§ 5100, 5102, 5106, 5107, 5126; 38 C.F.R. § 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). The notification obligation in this case was accomplished by way of letters from the RO to the Veteran dated in July 2006, March 2008 and June 2008. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006); Kent v. Nicholson, 20 Vet. App. 1 (2006). The claim was last readjudicated in a statement of the case dated in February 2011. Furthermore, based on the communications sent to the Veteran and his representatives over the course of this appeal, he has actual knowledge of the evidence he is required to submit in this case. Based on his contentions as well as the communications provided to him by VA, it is reasonable to expect that he understands what is needed to prevail. As to VA's duty to assist, the Board finds that all necessary development has been accomplished and that appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran's service treatment records (STRs) and all VA and private medical records have been obtained and associated with the claims file. The Board has also reviewed the Veteran's Virtual VA records. The Veteran was afforded an opportunity for a personal hearing, but declined. During the pendency of this appeal, the Veteran was examined by VA for the claims for an increased rating for epididymitis and loss of use of a creative organ. The Board finds that the examinations, particularly the August 2010 examination, were thorough and adequate upon which to base a decision on the merits of the issues addressed in this decision, and there is no allegation or competent evidence indicating that there has been a material change in the severity of the Veteran's epididymitis since the last VA examination in August 2010. The examiners personally interviewed and examined the Veteran, elicited a medical history and provided the information necessary to evaluate his epididymitis under the applicable rating criteria. An examination was not undertaken for the claim to reopen service connection for bilateral inguinal hernia. An examination is not needed to reopen the claim of service connection for bilateral inguinal hernia because new and material evidence has not been submitted. See 38 C.F.R. § 3.159(c)(4)(iii). Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Accordingly, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. New and Material Evidence to Reopen Claim Pertinent procedural regulations provide that "[n]othing in [38 U.S.C.A. § 5103A] shall be construed to require [VA] to reopen a claim that has been disallowed except when new and material evidence is presented or secured, as described in [38 U.S.C.A. § 5108]." 38 U.S.C.A. § 5103A(f) (West 2002). Reopening a claim for service connection which has been previously and finally disallowed requires that new and material evidence be presented or secured since the last final disallowance of the claim. 38 U.S.C.A. § 5108; Evans v. Brown, 9 Vet. App. 273, 285 (1996); see also Graves v. Brown, 8 Vet. App. 522, 524 (1996). New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the United States Court of Appeals for the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant a claim. In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). In Elkins v. West, 12 Vet. App. 209 (1999), the Court of Appeals for Veterans Claims (Court) held the Board must first determine whether the claimant has presented new and material evidence under 38 C.F.R. § 3.156(a) in order to have a finally denied claim reopened under 38 U.S.C.A. § 5108. Then, if new and material evidence has been submitted, the Board may proceed to evaluate the merits of the claim, but only after ensuring that VA's duty to assist has been fulfilled. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The Court also held that the law should be interpreted to enable reopening of a claim, rather than to preclude it. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Even if no appeal is filed, a rating decision is not final if new and material evidence is submitted within the appeal period and has not yet been considered by VA. 38 C.F.R. § 3.156(b); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). In October 1989, the Board denied service connection for bilateral inguinal hernias. Board decisions are final when issued. 38 C.F.R. § 20.1100 (2013). By rating action in June 2000, the RO reopened and denied the claim for bilateral inguinal hernia on the merits, including as secondary to service-connected epididymitis. The RO determined there was no evidence of an inguinal hernia or injury in service or until many years thereafter, and no link between his service-connected epididymitis and the bilateral inguinal hernias. The Veteran and his representative were notified of this decision. However, the Veteran did not submit any new and material evidence within the year following the June 2000 rating decision, nor did he file a timely appeal to that decision. Therefore, that rating decision is final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2013). Historically, the STRs showed that the Veteran was hospitalized for four days for evaluation of pain in his left inguinal region and left scrotum after physical training in September 1969. The final diagnosis was epididymitis, and the Veteran was placed on light duty for 30 days. The STRs showed no further complaints, treatment, abnormalities or diagnosis for any similar symptoms or any recurrence of epididymitis in service. Private medical records showed that the Veteran was first treated for bilateral indirect inguinal hernias in September 1988, at which time he reported the onset of symptoms that morning and denied any prior history of similar problems. The records showed that the Veteran underwent bilateral inguinal hernia repair in November 1988. In the June 2000 rating decision, the RO reopened and denied the Veteran's claim because there was no evidence of an inguinal hernia or injury in service or until many years thereafter, and no link between his service-connected epididymitis and the bilateral inguinal hernias. Thus, in order for the Veteran's claim to be reopened, new evidence must have been added to the record since the June 2000 rating decision that addresses these bases. Relevant evidence submitted and obtained since the June 2000 rating decision consists of numerous VA and private medical and examination reports showing treatment for various maladies from 2001 to the present, lay statements from his wife and several friends, and a web article on the subject of epididymitis and orchitis. The additional medical records showed treatment for various maladies, including chronic prostatitis with related symptoms beginning in February 2006, additional surgery for left inguinal hernia repairs in November 2006 and April 2009 and for chronic back problem and associated neurological symptoms from an injury at work around 1996. While the additional medical records showed treatment for pain and other symptoms involving the lower abdomen and genitourinary system, they do indicate or otherwise suggest that there is or maybe a causal relationship between the Veteran's inguinal hernias and service or the service-connected chronic epididymitis. Thus, the evidence is not new and material. Similarly, while the lay statements provided a description of the Veteran's physical problems and how they impact on his daily living, they do not offer any competent evidence as to the etiology of his bilateral inguinal hernias. That is, none of the lay persons are shown to have any particular training or expertise to offer a medical opinion. The Veteran's statements concerning the history of his bilateral inguinal hernias were essentially the same information he reported previously and offered no additional or new information. Thus, the Board finds his additional statements are cumulative and redundant, do not raise a reasonable possibility of substantiating the claim, and do not trigger the duty to assist by providing a medical examination. Finally, the web article provided an overview of epididymitis and orchitis and included a discussion of the etiology; pathophysiology and the physical findings associated the disorders. While the article indicated that epididymitis can include pain in the inguinal region from inflammation or infection of the epididymis, it did not indicate or otherwise suggest that there is an etiological relationship between epididymitis and inguinal hernias. Thus, the article does raise a reasonable possibility of substantiating the claim. The evidence added to the record since the June 2000 rating decision shows continued treatment for recurring inguinal hernias, but does not show that they were present or had their onset in service, or that there is a causal relationship between the service-connected epididymitis and the bilateral inguinal hernias. See Cornele v. Brown, 6 Vet. App. 59, 62 (1993); Mintz v. Brown, 6 Vet. App. 277, 280 (1994) (medical evidence that merely documents continued diagnosis and treatment of disease, without addressing the crucial matter of medical nexus, does not constitute new and material evidence); see also Routen v. Brown, 10 Vet. App. 183, 186, (1997) ("[l]ay assertions of medical causation cannot suffice to reopen a claim under 38 U.S.C. 5108."). As such, the Board finds that the additional medical evidence does not raise a reasonable possibility of substantiating the claim or trigger the duty to assist by providing a medical examination. As the recently received evidence does not fulfill the threshold burden of constituting new and material evidence to reopen the finally disallowed claim, the benefit-of-the-doubt doctrine is not applicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). Increased Ratings - In General In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Epididymitis The Veteran is currently assigned a 10 percent evaluation under Diagnostic Code (DC) 7525 for epididymo-orchitis, which directs that the disability is to be rated as urinary tract infection. (For tubercular infections, which is not shown in this case, DC 7525 directs that the disability is to be rated in accordance with §§ 4.88 or 4.89.) Under DC 7525, urinary tract infections causing poor renal function should be rated as renal dysfunction. Recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times a year), and/or requiring continuous intensive management is to be rated 30 percent disabling. Long-term drug therapy, 1-2 hospitalizations per year and/or requiring intermittent intensive management is rated 10 percent disabling. (38 C.F.R. § 4.115b, DC 7525). In this case, the Veteran was examined by VA on three occasions during the pendency of this appeal, including in March 2007, July 2009, and August 2010. The Veteran's complaints and the clinical and diagnostic findings were not significantly different and showed no evidence of poor renal function or recurrent epididymitis. When examined by VA in March 2007, the Veteran denied any problems with erectile dysfunction and said that his ejaculation was normal. While the Veteran reported that he had recurrent episodes of epididymitis about five times a year requiring antibiotic treatment, the medical reports of record do not substantiate his assertions or show any hospitalizations or treatment for chronic epididymitis. That is, while the evidence showed that the Veteran was treated for recurrent inguinal hernias and other genitourinary problems on numerous occasions during the pendency of this appeal, they do not show any hospitalizations or treatment for recurrent episodes of epididymitis. The evidence shows that the Veteran has additional genitourinary problems unrelated to his epididymitis, including chronic prostatitis, benign prostatic hypertrophy and neuropathy associated with his multiple inguinal hernia repairs and low back disability. (See, i.e., February 2006 and August 2007 VA outpatient notes). In fact, the evidence showed that the Veteran's hospitalizations were primarily for chronic prostatitis with associated urinary tract infections and recurrent inguinal hernias. Thus, while the Veteran experiences pain and tenderness in and around his scrotum, the medical reports do not show any evidence of recurrent symptomatic infection requiring drainage, frequent hospitalizations or continuous intensive management associated with epididymitis. The Board notes that while the VA examiner in March 2007 reported that the Veteran had more than four urinary tract infections and required hospitalized for drainage three or more times in the past 12 months, he did not review the claims file and relied primarily on the Veteran's self-reported history. The fact that the examiner did not mention the Veteran's chronic prostatitis or any related treatment, and indicated that there was no other significant genitourinary history demonstrates his lack of knowledge of the Veteran's medical history. Thus, the Board finds that the reported history of recurrent infections and multiple hospitalizations for epididymitis is of little probative value. The pertinent objective findings on the March 2007 VA examination included tenderness of both testicles with a small spermatocele on the left and normal seminal vesicles on the right. The examiner also indicated that the testicles were 2/3 of normal size testicle. Similarly, when examined by VA in July 2009, the examiner indicated that the claims file and private medical records were not available for review and that only the electronic CPRS file was reviewed. The Veteran denied having any recurrent urinary tract infections or acute nephritis. The Veteran reported that his only incapacitating episode in the past 12 months was for a left inguinal hernia repair in April 2009, and he denied any catheterization or drainage procedures. The diagnoses included chronic epididymitis post left inguinal hernia repair with left orchiectomy. When examined by VA in August 2010, the examiner indicated that the claims file was reviewed and included a detailed description of the Veteran's complaints, medical history and the findings on examination. The examiner indicated that there was no history of recurrent urinary tract infections, renal dysfunction or renal failure, obstructive voiding, acute nephritis or hydronephrosis. The Veteran reported erectile dysfunction and absence of ejaculation, which the examiner indicated was most likely due to neurologic disease. On examination, there was some tenderness in both testicles and the epididymis/spermatic cord. The right testicle was 2/3 of normal size, and the left testicle was normal size. An ultrasound study of the scrotum in June 2010 showed bilateral hydroceles with no evidence of epididymitis, orchitis, testicular mass, testicular torsion or varicocele, and a 2-cm left epididymal cyst. The diagnoses included chronic epididymitis, erectile dysfunction, and bilateral inguinal repairs with associated peroneal neuropathy, and benign prostatic hypertrophy. The examiner indicated that the Veteran's erectile dysfunction had several causes such as depression, chronic pain medications, inguinal pain, and chronic low back pain. She stated could not offer an opinion as to the specific cause of the Veteran's erectile dysfunction without resorting to speculation as the recent scrotal ultrasound and physical examination showed both testicles present. However, she further explained that there were multiple causes for the Veteran's erectile dysfunction including depression, chronic pain medications, inguinal pain, and chronic low back pain, but the chronic epididymitis was not the cause of the erectile dysfunction, benign prostatic hypertrophy, or inguinal pain. In this case, the objective evidence of record does not show that the Veteran's service-connected epididymitis manifests with symptoms that meet or more nearly approximate the criteria required for a higher rating of 30 percent. That is, the service-connected epididymitis does not manifest with poor renal function; or recurrent symptomatic infection requiring drainage/frequent hospitalization (more than two per year); or requiring continuous intensive management for urinary tract infections associated with his epididymitis. Rather, the competent evidence reflects that his epididymitis has been essentially asymptomatic. While the Veteran believes that his service-connected epididymitis is more severe than reflected by the 10 percent evaluation currently assigned, the objective evidence of record does not show that his disability more nearly approximates the criteria for a higher evaluation. Accordingly, an increased rating for chronic epididymitis is not warranted. In light of the discussion above, the Board finds that the 10 percent evaluation assigned for the Veteran's chronic epididymitis accurately depicts the severity of the condition during the pendency of this appeal, and there is no basis for higher staged ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); see also, Fenderson v. West, 12 Vet. App. 119 (1999). Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or to the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1)(2012); Thun, 22 Vet. App. at 116. The rating criteria in this case are not inadequate. An evaluation in excess of the assigned rating is provided for certain manifestations of the service-connected chronic epididymitis, but the evidence reflects that those manifestations are not present in this case. The Veteran's primary complaint is pain and tenderness in his testicles. However, the evidence shows that his symptoms are primarily associated with his nonservice-connected inguinal hernias, and that his epididymitis has been essentially asymptomatic. That is, the Veteran is not shown to have any additional symptoms associated with his epididymitis. Moreover, there is no evidence of marked interference with employment or frequent periods of hospitalization due to his epididymitis. Accordingly, referral for consideration of an extra-schedular rating is not warranted. Finally, the Board notes that, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the Board finds that a claim for a TDIU was not expressly raised by the Veteran or reasonably raised by the record. The record showed that the Veteran has been unemployed since sustaining a back injury at work in 1996, and that he has been unable to work since then. Moreover, the objective findings of record do not show or otherwise suggest that the Veteran's chronic epididymitis, which is his only service-connected disability, has rendered him unemployable and indeed he does not contend otherwise. Loss of Use of a Creative Organ VA provides special monthly compensation if a service member, as a result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organs. 38 U.S.C.A. § 1114 (k) (West 2002 & Supp. 2013). Loss of use 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. 38 C.F.R. § 3.350(a)(1). Concerning the Veteran's claim for loss of use of a creative organ manifested as erectile dysfunction, the Board finds that special monthly compensation is not warranted based on loss of use of a creative organ. Service connection is only in effect for epididymitis. The evidence of record shows that the loss of use of a creative organ first manifested many decades after separation from service. The evidence also shows that the Veteran had normal erectile function and ejaculation prior to his left inguinal hernia repair in April 2009, and that his erectile dysfunction began shortly after the surgery. In July 2009, a VA examiner incorrectly reported that the Veteran underwent left inguinal hernia repair with removal of the left testicle in April 2009. However a review of the April 2009 surgical records indicated that while excision of the testicle was considered, it was not removed. Furthermore, an ultrasound of the Veteran's scrotum in June 2010 showed that both testicles were present. In August 2010 a VA examiner opined, unequivocally, that the loss of use of a creative organ, manifested as erectile dysfunction, was not due to the Veteran's service-connected epididymitis. Rather, the erectile dysfunction was most likely due to neurologic disease. The examiner further opined that the Veteran's erectile dysfunction had several causes such as depression, chronic pain medications, inguinal pain, and chronic low back pain. She indicated that she could not offer an opinion as to the specific cause of the Veteran's erectile dysfunction without resorting to speculation; however, she explained that while there were multiple causes for the Veteran's erectile dysfunction including depression, chronic pain medications, inguinal pain, and chronic low back pain, the chronic epididymitis was not the cause of the erectile dysfunction. The Board finds that the VA medical opinion persuasive, as it was based on a thorough examination of the Veteran and included discussion of all relevant facts. See Wray v. Brown, 7 Vet. App. 488, 493 (1995). Furthermore, the Veteran has not presented any competent medical evidence to rebut that opinion. Thus, the most probative evidence of record consists of the August 2010 medical opinion. While the Veteran is competent to describe his experiences and symptoms, the etiology of his erectile dysfunction may not be diagnosed via lay observation alone and he is not shown to have the expertise to provide a competent medical opinion concerning the complex medical question as to the nature or etiology of his erectile dysfunction. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board thus finds that the weight of the competent evidence demonstrates that the loss of use of a creative organ manifested by erectile dysfunction is not caused by any in-service event or service-connected disability, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER New and material evidence has not been received to reopen the claim of service connection for bilateral inguinal hernia, including secondary to service-connected chronic epididymitis, and the claim is not reopened. An increased evaluation for chronic epididymitis is denied. Entitlement to SMC based on loss of use of a creative organ is denied. REMAND Concerning the claim of service connection for restless leg syndrome secondary to service-connected epididymitis, the Board finds that the RO's denial of this claim in August 2009, was premature and failed to undertake any meaningful development prior to ruling on this matter. In this case, the evidence of record showed that the Veteran was diagnosed with restless syndrome and started on medication in 2008, and that he is service-connected for chronic epididymitis. Based on these facts, VA has an obligation to obtain a medical opinion as to whether there is a causal connection between the Veteran's restless leg syndrome and his service-connected epididymitis. Part of VA's duty to assist under the Veterans Claims Assistance Act of 2000 (VCAA) is to provide the Veteran with an examination if, as in this case, there is competent lay or medical evidence of a current disability or persistent or recurrent symptoms of disability, and the evidence indicates that the current disability may be related to an event in service or with another service-connected disability. 38 C.F.R. § 3.159(c)(4)(i) (2013). As the Veteran has never been examined by VA to determine the nature and etiology of his claimed restless leg syndrome, including whether it is secondary to his service-connected epididymitis, additional development is necessary. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and his representative and request that they provide sufficient information, and if necessary, authorization, to obtain any additional private and VA treatment records pertinent to the claim on appeal. Then, obtain non-duplicative copies of all records identified by the Veteran. 2. The Veteran should be afforded a VA examination by a qualified physician to determine the nature and etiology of the Veteran's restless leg syndrome. All indicated tests are to be performed. The claims folder must be made available to the examiner for review, and a notation to the effect that this record review took place should be included in the report. The examiner should provide a response to the following: Does the Veteran have restless leg syndrome? If so, is it at least as likely as not that it is proximately due to, the result of, or aggravated by the service-connected chronic epididymitis? Note: The term "aggravation" in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. The examination report must include a complete rationale for all opinions expressed. If the examiner determines that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 3. Then, readjudicate the claim. If the benefit sought remains denied, issue a Supplemental Statement of the Case and return the case to the Board Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran need take no action unless otherwise notified. The Veteran has the right to submit additional evidence and argument on the matter 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. 2013). ______________________________________________ D. JOHNSON Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs