Citation Nr: 1526680 Decision Date: 06/23/15 Archive Date: 06/30/15 DOCKET NO. 11-08 964A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for obstructive sleep apnea. 2. Entitlement to service connection for pelvic floor dysfunction with nocturia. REPRESENTATION Appellant represented by: Julie L. Glover, Attorney at Law ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran had active military service from July 2001 to August 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The claims file is now entirely in VA's secure electronic processing systems, Virtual VA and Veterans Benefits Management System (VBMS). FINDINGS OF FACT 1. It is more likely than not that the Veteran's pelvic floor dysfunction with nocturia is related to his active duty service. 2. It is more likely than not that the Veteran's sleep apnea is related to his active service or a service connected disability. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the appellant's favor, pelvic floor dysfunction with nocturia was incurred in active service. 38 U.S.C.A. §§ 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2014). 2. Resolving reasonable doubt in the appellant's favor, sleep apnea was incurred in service or is proximately due to or the result of a service connected disability. 38 U.S.C.A. §§ 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (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 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). In light of the favorable outcome of this appeal, any perceived lack of notice or development under the VCAA should not be considered prejudicial. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may also be warranted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To prevail on the issue of service connection there must be evidence of a current disability, in-service incurrence or aggravation of a disease or injury; and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection can be established for any disorder that is proximately due to or the result of a service connected disorder or if a service connected disorder causes aggravation of another disorder, that disorder may be service connected to the extent of the aggravation. 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran's service treatment records indicate that in November 2001, the Veteran underwent cystoscopy for intermittent gross hematuria. It was noted that the Veteran was initially treated for a urinary tract infection with resolution of hematuria but that he had two more episodes the prior month. Intravenous Pyelogram (IVP) was normal, and urinalysis was negative. Flexible cystoscopy was performed to rule out pathology in bladder or urethra. The urethra and bladder were carefully inspected. No urethral strictures were noted, no active bleeding was seen, and no mucosal abnormalities were seen. Clear efflux from both ureteral orifices was seen. In April 2002, the Veteran complained of a urethra problem and more specifically discharge status post urination. Assessment was genital discharge. In May 2002, he complained of possible urinary tract infection and blood in his urine with frequency, hesitancy, and incomplete emptying. The provider noted a history of painless hematuria after running with normal cystoscopy and IVP. The provider also noted that a profile had been issued for no running and that the Veteran started running in January 2002. Urinalysis was positive for blood. Assessment was hematuria. In May 2003, the Veteran presented for follow up for urethra problems including history of urethral drainage. The Veteran underwent VA examination in November 2009 at which time the examiner diagnosed the Veteran as having pelvic floor dysfunction with symptoms of increased frequency, nocturia, dysuria, and incontinence. The examiner opined that the Veteran's diagnosis of pelvic floor dysfunction was not related to his athlete's hematuria which he had in service. In support of his claim, the Veteran submitted a June 2014 statement from Dr. Ellis who noted that in basic training, he had an acute onset of pain in his pelvic area and that on work up of his genitourinary system, hematuria was found. Dr. Ellis stated that he did not fault the initial physician's diagnosis of athletic hematuria. Dr. Ellis explained that there was hematuria from straining of the bladder and pelvis, that a complete work up had been conducted subsequently, and that the Veteran continued to have hematuria which indicated the straining of the pelvic floor and bladder were caused by a permanent anatomical change resulting in symptoms of urgency, nocturia, dribbling, loss of penile erectile power, and abdominal pelvic pain. Dr. Ellis noted that it was easier for him to make the diagnoses having seen the chronology and continuation of symptoms and the work up by the VA Medical Center. The Board notes that there is a difference of opinion among the medical professionals. In deciding whether the Veteran's pelvic floor dysfunction with nocturia is related to his active duty service, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Evans v. West, 12 Vet. App. 22, 30 (1998). That responsibility is particularly onerous where medical opinions diverge. At the same time, the Board is mindful that it cannot make its own independent medical determinations and that there must be plausible reasons for favoring one medical opinion over another. Id. However, a more detailed discussion of the specific opinions, credentials of the diagnosticians, and circumstances of opinions in this case would not clarify the matter. It would merely highlight that there is not a clear, rational basis for the Board to prefer one opinion to another. Accordingly, the Board finds that the competent medical evidence of record, both for and against the finding that the Veteran's pelvic floor dysfunction with nocturia is related to his active duty service, are in a state of equipoise. Accordingly, reasonable doubt is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. With respect to the issue of entitlement to service connection for obstructive sleep apnea, the Veteran underwent VA examination in August 2011 at which time the examiner noted that the Veteran reported being diagnosed as having insomnia in 2008 and as having sleep apnea in 2009. The Veteran reported that he was given a CPAP machine at that time and that he had a sleep study done in March 2009 and that the diagnosis was likely sleep apnea. The examiner opined that this is caused by or a result of military service. Further rationale was not provided. In his June 2014 statement, Dr. Ellis noted that when the Veteran left the Army, he weighed 200 pounds and was not having any difficulty sleeping. After the Army and with his posttraumatic stress disorder (PTSD), panic disorder, and depression, the Veteran began eating a lot, drinking, and gained weight. Dr. Ellis noted that the Veteran developed severe sleep apnea and had been on a CPAP machine since 2008. Dr. Ellis opined that it was as likely as not that the Veteran's PTSD, panic disorder, and depression caused him to continue eating and drinking causing him to gain weight which contributed to and aggravated his sleep apnea. In addition, Dr. Ellis opined that the medications for his PTSD, panic disorder, and depression slowed down his breathing and contributed to his sleep apnea at night. Given these two opinions, both in some way relating the sleep apnea to service or service connected disability, the Board resolves reasonable doubt as to the limited rationales and grants service connection for sleep apnea. ORDER Entitlement to service connection for pelvic floor dysfunction with nocturia is granted. Entitlement to service connection for sleep apnea is granted. ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs