Citation Nr: 1630092 Decision Date: 07/27/16 Archive Date: 08/04/16 DOCKET NO. 98-06 513A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for urethral stricture with a history of urethrotomy, to include as secondary to service-connected urethral lithiasis. 2. Entitlement to a rating in excess of 10 percent for renal lithiasis from April 15, 2010. 3. Entitlement to a compensable rating for condyloma acuminata with herpes simplex virus II (HSV II) from April 15, 2010. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran and his wife ATTORNEY FOR THE BOARD M.H. Stubbs, Counsel INTRODUCTION The Veteran served on active duty from July 1979 to June 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 1997 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This case was previously before the Board in January 2005, August 2009, April 2012, June 2014, August 2014, and November 2015. In April 2012, the Board provided decisions for the issues on appeal. In September 2013, VA informed the Veteran of an option to receive a new discission for the Board to correct an potential errors in his case relating to the duties of the presiding Veterans Law Judge who held his August 2004 hearing. The Veteran requested that he receive a new decision, and a new hearing. In June 2014, the Board vacated the April 2012 decisions. The August 2014 decision remanded the issues so that the Veteran could testify at a new Board hearing. The Veteran appeared and testified at a June 1, 2015 Board hearing. Unfortunately, the hearing did not record properly and a transcript could not be made of the hearing, and it could not be entered into evidence. On June 7, 2015, the Veteran and his representative were informed that the hearing could not be transcribed and offered the Veteran the opportunity to have an additional hearing. The Veteran and his representative did not respond to this request. The 2004 Board hearing transcript is contained in the record. The Board notes that although the Veteran had two Board hearing before two different Veterans Law Judges, the 2015 Veterans Law Judge does not have to participate in this decision, and a three-member panel of judges is not necessary. VA regulations require that any Veterans Law Judge who conducts a hearing on appeal must participate in any decision made on that appeal. If more than one Veterans Law Judge has conducted a hearing, the matter will be decided by a three-member panel. 38 U.S.C.A. § 7102; 38 C.F.R. § 20.707. Additionally, a veteran is entitled to have an opportunity for a hearing before all Veterans Law Judges who will ultimately decide the appeal. Arneson v. Shinseki, 24 Vet. App. 379 (2011). Arneson noted the significance placed on sworn testimony is demonstrated by the fact that "the Board 'must consider' and 'provide adequate reasons or bases for its rejection' of any sworn testimony." Arneson citing Ashely v. Brown, 6 Vet. App. 52, 56 (1993). Here, without a transcript of the 2015 hearing, the Board is unable to consider the sworn testimony as that testimony has been lost. While a Veterans Law Judge may make some notes during a hearing of his or her impression of the claims, they are not so flushed out as to be useful without the transcribed testimony. And given the number of hearings a Veterans Law Judge hears over a course of months, it would be unreasonable to assume that he or she may remember the details of any one case. As the 2015 hearing was not transcribed, it does not become a part of the evidence relied on by the Board. Notably, the Veteran was advised that the transcript could not be provided, and was offered the opportunity of an additional hearing; however, he did not respond. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims (Court) held that a claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is part of a rating claim when unemployability is expressly raised by a veteran or reasonably raised by the record during the rating appeal. The Veteran has claimed TDIU as a result of his psychiatric and lumbar spine disabilities. On his most recent claim for TDIU, he indicated he was unable to work due to his psychiatric disorder. In an April 2016 rating decision, the RO denied entitlement to TDIU and denied entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD). The Veteran has a year to file a timely notice of disagreement with this decision, from the date of notice of the decision. 38 C.F.R. § 20.302(a). Thus, the Veteran's claim of entitlement to TDIU has specifically excluded the issues addressed in this decision, and the issues of TDIU and an increased rating for PTSD (upon which the Veteran has argued he is entitled to TDIU) are not currently ripe for Board consideration. The issue(s) of entitlement to service connection for urethral stricture is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the period from April 15, 2010, the Veteran's renal lithiasis manifested by recurrent stone formation with occasional episodes of colic, with no evidence of infection, required catheter drainage, renal dysfunction or severe hydronephrosis; no required drug therapy, diet therapy or invasive or non-invasive procedures more than twice a year. 2. For the period from April 15, 2010, the Veteran's condyloma acuminata with HSV II has manifested by intermittent genital warts and herpes lesions associated with slight crusting, oozing, or itching, and affecting a small, unexposed area of less than 5 percent of the total body, with the use of oral and topical medications but no systemic immunosuppressive medications; with no evidence of ulceration, marked disfigurement, exceptionally repugnant condition, systemic or nervous manifestations, scarring or limitation of function. CONCLUSIONS OF LAW 1. For the period beginning April 15, 2010, the criteria for a rating in excess of 10 percent for renal lithiasis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.321(b)(1) , 4.3, 4.7, 4.10, 4.115a, 4.115b, Diagnostic Codes 7508, 7509 (2015). 2. For the period beginning April 15, 2010, the criteria for a compensable rating for condyloma acuminata with HSV II have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.321(b)(1) , 4.3, 4.7, 4.10, 4.118, Diagnostic Codes 7801-7806, 7819 (1997, 2003, & 2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA's duty to notify was satisfied by letters dated in May 2003, March 2004, May 2004, February 2005, and November 2009. See 38 U.S.C.A. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). As noted above, the Veteran testified as to each of his claimed disabilities during the August 2004 Board hearing. The Veteran was afforded a 2015 Board hearing in relation to the determination in Bryant v. Shinseki, 23 Vet. App. 488 (2010) (discussing the requirements of 38 C.F.R. 3.103(c)(2) ). However, the 2015 hearing could not be transcribed. The Veteran did not reply to an option to have a third hearing address his claims. Concerning the duty to assist, the record contains the Veteran's service treatment records, Social Security Administration disability records, VA treatment records, and private treatment records. The Board notes that the complete records concerning the Veteran's workers' compensation were not obtained, due in part to his failure to fully complete the necessary authorization. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (stating that VA's duty to assist in developing the pertinent facts and evidence in connection with a claim is not a one-way street, and the Veteran has a responsibility to cooperate in such development). There is no indication that the absence of any records concerning the workers' compensation claim will result in prejudice as to this issues addressed herein. The Veteran has also been afforded several VA examinations concerning his claimed disabilities. As directed in the prior remands, he was afforded VA examinations concerning the nature and etiology of his claimed urethral strictures, as well as to determine the current severity of his renal lithiasis and condyloma acuminata with HSV II, in April 2010 and January 2016. The examiner reviewed the records, interviewed the Veteran, and provided nexus opinions with rationales. The Board notes that the Veteran's representative has argued that the most recent genitourinary examination was inadequate, in that the examiner was unable to offer an opinion as to the etiology of the claimed urethral strictures without resorting to speculation. See June 2016 brief. The Board is remanding the service connection claim for an addendum opinion. VA has satisfied its duties to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceedings. As such, the Veteran will not be prejudiced by a decision on these claims at this time. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. All reasonable doubt as to the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In determining the propriety of the initial rating assigned after a grant of service connection, the evidence since the effective date of the grant of service connection must be evaluated and staged ratings must be considered. Staged ratings are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the course of the appeal. Fenderson v. Brown, 12 Vet. App. 119, 126-27 (1999). Renal lithiasis In the November 2015 decision, the Board provided staged ratings for renal lithiasis. The Veteran has a 10 percent rating for the period prior to March 14, 2001, a 30 percent rating for the period from March 14, 2001 to February 8, 2006, and a 10 percent rating for the period beginning February 9, 2006. The Board remanded the issue of entitlement to a rating in excess of 10 percent from April 15, 2010 (at the time, this was the date of the last VA examination for renal lithiasis in the record) for additional development. The Veteran was assigned an initial noncompensable rating for renal lithiasis (or kidney stones) effective as of April 29, 1996. The rating was assigned under 38 C.F.R. § 4.115b, Diagnostic Code (DC) 7508, for nephrolithiasis. This code provides that nephrolithiasis should be rated as hydronephrosis, except where there is recurrent stone formation requiring one or more of the following: (1) diet therapy; (2) drug therapy; or (3) invasive or non-invasive procedures more than two times per year. If evaluated under this code, the rating assigned will be 30 percent. 38 C.F.R. § 4.115b, DC 7508. Hydronephrosis warrants a 10 percent rating where there is only an occasional attack of colic, not infected and not requiring catheter drainage. A 20 percent rating is warranted for frequent attacks of colic, requiring catheter drainage. A 30 percent rating is warranted for frequent attacks of colic with infection (pyonephrosis), kidney function impaired. Severe hydronephrosis is to be rated as renal dysfunction. 38 C.F.R. § 4.115b, DC 7509; see also 38 C.F.R. § 4.115a (setting forth the criteria for rating renal dysfunction from 0 to 100 percent). In April 2010, the Veteran was afforded a VA examination in conjunction with his claims. He reported he could not recall when he had his first kidney stone but that it happened while he was in service. He stated that since then, he has passed multiple stones; all of them were small and did not involve medical intervention except once in 1995 where he received laser treatment to break down stones in his right kidney. He reported he had passed about 20 stones in the last 10 years, with the last one a month ago. He stated he did not seek any treatment for his most recent kidney stone. He reported back pain, nausea and a burning sensation which would resolve after passing the small stones. Ultrasounds in 2006 and a CT in 2005 did not reveal kidney stones. Testing from October 2009 showed he did not have renal dysfunction, and his renal blood tests were normal. He had no urinary symptoms at the time of the examination or during the periods when he was not directly passing a stone. His erectile dysfunction was noted to not be related to his kidney stones. May 31, 2012 and November 26, 2012 records of the Veteran's prescription medications did not include medication for kidney stones. In July 2014, the Veteran reported burning with urination for three days and that his urine was dark in the morning. He denied back or lower abdominal pain. He reported recurring urinary tract infections "all [his] life." A July 25, 2014 letter sent to the Veteran by his VA physician noted that he had unusual laboratory results and he wanted the Veteran to have a CT of his kidneys and bladder done, and repeat blood testing to test for kidney function. In January 2015, the Veteran underwent a CT of his abdomen and pelvis due to hematuria. The CT showed an 8mm calculus in the lower pole of the left kidney and a 4 mm calculus in the lower pole of the left kidney. There were small bilateral benign-appearing renal cysts. Ureters was in normal position and of normal size. He was assessed with bilateral renal calculi, one in each kidney, which have appeared since the prior January 2012 examination. A tiny calcification in the subcortical region of the midpole of the left kidney had not changed. A February 2015 genitourinary history included the Veteran's report that he had passed three stones in his life, with his most recent two years prior. He denied current voiding issues, but reported two or three episodes of dysuria since his service, which he stated were diagnosed as urinary tract infections. Due to a finding of hematuria in a urine sample, the Veteran underwent a cystoscopy. The post-operative diagnosis was "negative cystourethroscopy." The anterior and membranous urethras appeared normal. The posterior urethra revealed only 4 gm of resectable tissue. The bladder was then entered. There were no tumors or stones observed, and the bladder had normal capacity. The urethral orifices appeared normal. In March 2015, a VA treatment record noted "gross bloody urine intermittently for several days associated with left flank pain radiating to the groin. Symptoms improved at present and [he] denies any pain." The physician noted it appeared to be "renal calculi. Recent urology workup unremarkable" according to the Veteran. The pain was resolved at the present time and it appeared that the Veteran passed the stone. An October 2015 record noted that the Veteran was seen for a "follow up from last week related to hematuria and medication compliance." The Veteran reported that his urine is clear yellow now. He denied blood in urine since his last visit. He stated he felt better and will start taking medications as prescribed. It is unclear what medications are being referred to in the record. Other records from the months prior indicated that the Veteran had discontinued his psychiatric medications. In the October 2015 record, the primary care physician noted that if the Veteran continued to have issues he should call, and that he was being referred to mental health. Another record noted that the Veteran had occasional hematuria, "have stones. Has had cysto." Records from June 2015 and December 2015 included medication lists for the Veteran. The medication lists did not include ongoing medication for renal stones. In January 2016, the Veteran was afforded another VA examination. The Veteran was noted to have been diagnosed with ureterolithiasis in 1996. He could not recall exactly when he had his first kidney stone pass, but he stated it happened while he was in the service. Since his in-service stone, he had passed multiple stones. All of the stones were small and he "did not go to see anybody about it except once" in 1995 when he went to the Tampa VA medical center and his right kidney was treated with a laser to break down the stones. He stated that this treatment in 1995 was the only time he received actual treatment in a hospital for kidney stones. He believes he passed about 20 stones in the past 10 years, with his last stone passed about a month ago. He did not see a doctor about any of these kidney stones because they were small and he just drank water and passed them. He reported he did not have any testing and did not go to the emergency room. He reported pain in his back, nausea and a burning sensation or dysuria and hematuria which resolved after passing the small stone. Then, the examination report noted that he "currently he said he has not passed kidney stone for at least a couple of years and when he passed them before they were small and it took place at home and did not see a doctor about it." The Veteran was noted to not have renal dysfunction, and he was not taking continuous medication for his kidney stones. The examiner found that the Veteran's kidney stones did not impact his ability to work. The Board notes that the Veteran's report to the 2016 VA examiner that he had not passed a stone in a couple of years is incorrect. VA treatment records include that he passed a stone in 2015. After finding blood in his urine, an ultrasound showed a kidney stone in each kidney in 2015. The treatment records do not show that the Veteran has been prescribed a diet or medications related to his kidney stones. The Veteran has also not indicated in the 2016 examination or in statements to the VA that he is on a prescription diet or medications for his kidney stones. He has stated in the past that when he feels the pain in his back and flank which indicates he has a kidney stone, he will drink a lot of water and wait to pass the stone. Thus, after a review of the records, the Board finds that there is no evidence of the Veteran's renal lithiasis requiring diet therapy, drug therapy, invasive or non-invasive procedures more than two times per year, catheter drainage, infection or severe hydronephrosis. As such, entitlement to a rating in excess of 10 percent is not warranted. All possibly applicable diagnostic codes have been considered, and there is no basis to assign a higher evaluation for the Veteran's renal lithiasis. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Condyloma acuminata with HSV II The Veteran was assigned an initial noncompensable rating for condyloma acuminata with HSV II (herpes) based on his 1996 claim. The Board notes that condyloma acuminata refers to lesions on the genitals, or genital warts. See Dorland's Illustrated Medical Dictionary 409 (31st ed. 2007). Such rating was assigned under 38 C.F.R. § 4.118, DC 7819, for benign skin neoplasms. In the November 2015 decision, the Board continued the Veteran's noncompensable rating for condyloma acuminata with HSV II for the period prior to April 15, 2010, and remanded the rating thereafter for an additional examination and records. During the April 2010 VA examination, the Veteran reported that he acquired a herpes virus infection in the Philippines in 1991. He stated that since then he had flare-ups of herpes symptoms during which he will see a small pimple or ulcer on the penis which hurts or burns and he is currently being treated with Famciclovir twice a day, which helped reduce the attacks. The frequency of his flare-ups was reported as once every two months. The attacks were mild with the medication and resolved spontaneously. The examiner described the Veteran's herpes as an "intermittent course and he is using medication." Examination of the skin, including the penis, found no current lesions or herpes-like ulcers or any condyloma acuminata lesions. Thus the percentage of exposed area was zero percent, and the percentage of his entire body affected was zero percent. There was no scarring and photographs were not taken. There was no evidence of exfoliation or exudation, and no evidence of itching. The examiner called his herpes virus condition to be recurrent with clearing of the herpes lesions between flare-ups. VA treatment records included a November 2015 record of the Veteran's wife calling to report that he was having a flare-up and needed his prescription Acyclovir renewed. The Veteran had not used Acyclovir for two years, so he needed to treat the breakout as "acute," which included a higher dose than when he used the medication for daily suppression. The Veteran was provided an updated VA examination in January 2016 to determine the current severity of his skin conditions. The Veteran denied having condyloma acuminata. He stated that he had herpes virus infection from his service in the Philippines in 1991. He reported that since then he gets attacks of herpes flare-ups during which he will see a small pimple or ulcer on his penis, which hurts or burns. "The attacks are mild with the medication and they resolve spontaneously." Then, the examiner noted that the Veteran had no current condyloma acuminatum and the Veteran reported his last herpes attack or flare-up was three years ago. He was taking Acyclovir when necessary. During the examination, the examiner did not see any lesions of condyloma acuminatum or herpes simplex virus 2. The Veteran did not have any scars associated with his skin condition. The Board notes that the Veteran appeared to have had a herpes flare-up in November 2015, as his wife requested that his Acyclovir be renewed for a "flare-up." Although the Veteran did not see a physician at the time of the request for medication, the Board presumes he had a flare-up on that occasion despite stating during the January 2016 VA examination that his last flare-up was three years prior. The Board cannot account for the reasoning behind the disparity in the Veteran's report to the January 2016 VA examiner and what the VA treatment records reveal, other than he must have forgotten or been confused when answering the January 2016 examiner's question regarding his most recent outbreak. As this claim stems from a 1997 rating decision, the regulations pertaining to the evaluation of skin disabilities were amended twice. See 67 Fed. Reg. 49,590 (July 31, 2002) (effective August 30, 2002); 73 Fed. Reg. 54,708 (effective October 23, 2008). Where laws or regulations change while a claim is pending, the version most favorable to the Veteran applies, absent contrary Congressional or Secretarial intent. See Dudnick v. Brown, 10 Vet. App. 79 (1997); Karnas v. Derwinski, 1 Vet. App. at 312-13 (1991). In contrast, the 2008 amendments were specifically made effective only to applications received on or after October 23, 2008, although a claimant may request consideration under the amended criteria. See 73 Fed. Reg. 54,708. In this case, the Veteran's claim was received in 1996, and he has not requested consideration under the amended provisions. Therefore, the rating criteria in effect from October 23, 2008, forward are not for consideration. Accordingly, the Board will evaluate the Veteran's condyloma acuminata with HSV II under the criteria in effect prior to August 30, 2002, and the criteria in effect from August 30, 2002, through October 22, 2008, keeping in mind that the revised criteria may not be applied prior to the effective date of the change. The Board notes that the criteria for rating skin disabilities other than scars have remained the same from August 30, 2002, forward, so those criteria are also for consideration. Prior to August 30, 2002, the criteria of DC 7819 for benign new growths of the skin provided that such a disability was to be rated as scars, disfigurement, etc.; or as for eczema, dependent upon location, extent, and repugnant or otherwise disabling character of manifestations. 38 C.F.R. § 4.118 (1997). Eczema was assigned a noncompensable rating for slight, if any, exfoliation, exudation or itching, if on an unexposed surface or small area. A 10 percent rating was warranted for eczema with exfoliation, exudation or itching, if it involved an exposed surface or extensive area. A 30 percent rating was assigned for eczema with exfoliation or itching constant, extensive lesions, or marked disfigurement. A 50 percent rating was assigned for eczema with ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or if it was exceptionally repugnant. 38 C.F.R. § 4.118, DC 7806 (1997). Scars other than of the face, head, or neck, and non-burn scars were assigned a 10 percent rating for scars that were superficial, poorly nourished, with repeated ulceration; or for scars that were superficial, tender and painful on objective demonstration. Otherwise, scars could be rated based on limitation of function of the affected part. 38 C.F.R. § 4.118, DCs 7803, 7804, 7805 (1997). The Veteran is not entitled to a compensable rating for his condyloma acuminata or HSV II under these rating criteria. Specifically, he has had only slight crusting, oozing, or itching associated with intermittent and small lesions on an unexposed surface, namely, his penis. There is no evidence of ulceration, marked disfigurement, exceptionally repugnant condition, or systemic or nervous manifestations. As such, a 0 percent (noncompensable) rating is appropriate under DC 7806. Further, there is no evidence of scarring or limitation of function to warrant a rating under DCs 7803 to 7805. See 38 C.F.R. §§ 4.118 (1997). Effective August 30, 2002, DC 7819 provides that benign skin neoplasms are rated as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801 through 7805), or impairment of function. The Board notes that revised DC 7820 provides that infections of the skin not listed elsewhere (including viral diseases), provides that such condition should be rated under those same criteria, or as dermatitis (DC 7806), depending upon the predominant disability. See 38 C.F.R. § 4.118 (2003). As the Veteran's condition affects the genitalia, DC 7800 (scars of the head, face and neck) is not for consideration. Under 7801, scars in other areas that are deep or cause limited motion warrant a 10 percent rating where they exceed an area of 6 square inches (39 sq. cm.). Under 7802, scars in other areas that are superficial and do not cause limited motion warrant a 10 percent rating where they cover an area of 144 square inches (299 sq. cm.) or greater. Otherwise, superficial scars that are unstable (DC 7803) or painful on examination (DC 7804) warrant a 10 percent rating. Scars may also be rated on limitation of function of the affected part (DC 7805). 38 C.F.R. § 4.118 (2003). Under the revised provisions of DC 7806, dermatitis or eczema will be assigned a 10 percent rating where at least 5 percent, but less than 20 percent, of the entire body or of exposed areas are affected, or where intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than six weeks during the past 12-month period. Higher ratings are available where larger percentages of the entire body or exposed areas are affected, or longer periods of systemic therapy such as corticosteroids or other immunosuppressive drugs are required. See 38 C.F.R. § 4.118, DC 7806 (2003). In this case, there is no evidence of scarring or impairment of function due to the Veteran's condyloma acuminata or HSV II. As such, a rating is not warranted under DCs 7801 through 7805, as directed by DC 7819 for benign skin neoplasms. See 38 C.F.R. § 4.118 (2003). With regard to the criteria for eczema or dermatitis under DC 7806, the Veteran's lesions affect his genitalia, or an unexposed area, and there is no evidence of at least 5 percent of the body affected. The Veteran's medications to treat his genital warts or herpes have included Zovirax, Acyclovir, and Famvir or Famciclovir. Although these included oral forms, they are not immunosuppressive in nature. Accordingly, a compensable rating is also not warranted under DC 7806. See 38 C.F.R. § 4.118 (2003). Although not strictly applicable, the Board has reviewed the criteria in effect since the 2008 amendments. See 38 C.F.R. § 4.118, DCs 7800-7806, 7819, 7820 (2015). However, the Veteran is not entitled to a compensable rating under such criteria for his genital warts or herpes for the same reasons as discussed above (limited area covered by outbreak, and no systemic treatment.) During his August 20014 Board hearing, the Veteran testified that he began to notice warts on his feet and legs, and then later over his arms and his whole body, during his service in the Gulf War. He stated that the red, itchy bumps were intermittent and treated with creams and ointments. Although the Veteran complained of a full-body skin disorder, the claim on appeal is currently only for his service-connected condyloma acuminata (genital warts), with HSV II. As such, any other skin disorders and symptoms are separate from the issue on appeal. Moreover, the separate issue of service connection for stucco keratoses with verruca vulgaris, which concerned warts and other lesions on the body in general, was also denied in the September 1997 rating decision. The Veteran did not appeal from that determination but, rather, only appealed from the denial of service connection for the skin condition of condyloma acuminata with HSV II in his 1997 notice of disagreement. In summary, the Board finds that the Veteran is not entitled to a compensable rating for his condyloma acuminata with HSV II from the period beginning April 15, 2010. All possibly applicable diagnostic codes have been considered, and there is no basis to assign a higher evaluation for such disability. See Schafrath, 1 Vet. App. at 593. Staged ratings are not appropriate, as the severity of the Veteran's disability has been relatively stable throughout the period on appeal, and any increases in severity were not sufficient for a higher rating. See Fenderson, 12 Vet. App. at 126-27. Extra-schedular consideration The Board has also considered whether this case should be referred for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b) (1). An extra-schedular rating is warranted under such provision if a case presents such an exceptional or unusual disability picture, with such related factors as marked interference with employment or frequent periods of hospitalization, that it would be impracticable to apply the schedular standards. Analysis under this provision involves a three-step inquiry, and extra-schedular referral is necessary only if analysis under the first two steps reveals that the rating schedule is inadequate to evaluate the claimant's disability picture and that such picture exhibits such related factors as marked interference with employment or frequent periods of hospitalization. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Here, the manifestations of the Veteran's renal lithiasis and condyloma acuminata with HSV II are fully contemplated by the schedular rating criteria. Therefore, the rating criteria reasonably describe his disability levels and symptomatologies, and the rating schedule is adequate to evaluate his disability pictures for each condition. Moreover, there is no indication of any marked interference with employment or frequent periods of hospitalization due to such conditions. The Veteran has sought emergency department treatment for his renal lithiasis, but has not required hospitalization other than for testing procedures. As such, referral for consideration of an extra-schedular rating is not necessary. See Id. As noted above, the Veteran's most recent claim for TDIU was denied in a 2016 rating decision, along with his claim for an increased rating for PTSD, upon which he based his claim for TDIU. The Veteran has until one year from the notice of the April 2016 denial to file a notice of disagreement with that decision and begin the appeal process. Also, the claims currently on appeal have not been cited by the Veteran in terms of employability. As the preponderance of the evidence is against a higher rating for renal lithiasis, or a compensable rating for condyloma acuminata with HSV II, the benefit of the doubt doctrine does not apply. As such, his claims must be denied in this regard. 38 C.F.R. § 4.3. ORDER For the period beginning April 15, 2010, a rating in excess of 10 percent for renal lithiasis is denied. For the period beginning April 15, 2010, a compensable rating for condyloma acuminata with HSV II is denied. REMAND The Board recognizes that the Veteran's claims have been pending for an unusually long period of time; however, a remand is again required regarding his claim for service connection for urethral stricture. The Veteran has argued that he is entitled to service connection for urethral stricture on a direct basis, and as secondary to his service-connected renal stones. The Veteran argued during his 2004 hearing that he developed stricture as a result of the renal stones, including the removal of one stone in 1995, causing scarring. During the April 2010 VA examination, the examiner noted that there was no evidence of urethral stricture until four years after separation from service. The examiner noted that the Veteran's urethral stricture could not be related to service without resort to speculation. In November 2010, the examiner provided an addendum opinion. The examiner noted the Veteran was diagnosed with urethral stricture in November 1996, more than 4 years after service, and thus could not be related to service without resort to speculation. Regarding the secondary service connection theory, the examiner noted that the cause of the urethral stricture was not known. A July 1996 urethrogram showed a "very high post-bladder lip, unable to go over it into the bladder. No stricture seen. Urethra normal." In October 1996, the Veteran underwent a direct vision urethrotomy, and was diagnosed with urethra syndrome. A March 1998 urethrogram showed very minimal stricture of the mid-anterior penile urethra and decreased caliber of the penile urethra. A January 1999 record noted that the Veteran had minimal obstruction with fullness throughout the collecting system of the left kidney and ureter via intravenous pyelogram. An October 2003 urology treatment record noted that the Veteran had a urethral stricture after TURP [transurethral resection of the prostate]. In March 2004, a cystoscopy due to obstructive voiding symptoms found 20 grams of occlusive prostate tissue. The ureteral orifices were not seen well. A July 2005 VA examination noted that the Veteran had had "many reasons to have urethral stricture and also difficulty with urine stream which cannot all be related to the urethral stricture itself." The Veteran had a history of prostatic enlargement and he may have had a TURP or transurethral resection of the prostate, but it was unclear. He also had a history of two or three cystoscopies and has had a long-standing problem with kidney stones. The Veteran also has had a history of gonorrhea, which sometimes can have the residual of stricture. The examiner noted the Veteran had a history of urinary tract infections on many occasions, "and again he has multiple reasons for this including the kidney stones and the prostate problems, the strictures, the history of venereal disease and so on." The July 2005 examiner's report appears to infer that venereal disease, cystoscopy, TURP, and passage of kidney stones may all result in stricture. This examination report did not include a nexus opinion. In the November 2015 remand, the Board found that an additional nexus examination was necessary. Specifically, the Board requested (1) an opinion was to whether it was likely the Veterans' urethral disorder began during or was otherwise related to his service, and (2) an opinion as to whether it was likely his urethral disorder was caused by his service-connected disabilities, to include addressing the Veteran's claim that his passage of kidney stones and treatment for kidney stones resulted in scarring or stricture of his urethra. The January 2016 examination reiterated the April 2010 examination. The examiner again noted that the cause of the Veteran's urethral stricture was unknown and there was no evidence of urethral stricture in service. Because the Veteran's stricture was diagnosed four years after he left service, the stricture, "whatever its etiology, cannot be related to the service without resort to speculation based on the currently available information." The 2016 examination report did not address whether the passage of kidney stones, cystoscopies, TURP, or venereal disease are possible causes of urethral stricture. In a June 2016 appellant's brief, the Veteran's representative noted that the "bald statement that it would be speculative for the examiner to render an opinion as to etiology" was ambiguus. The representative noted that the examiner did not state whether there was a lack of information that could be cured with testing, whether the speculation was based on the bounds of currently known medical standards, or whether the examiner lacked the expertise to provide such an opinion. On remand, the Board requests an addendum opinion with an accompanying detailed explanation. Accordingly, the case is REMANDED for the following action: 1. Return the claims file to the 2016 examiner, or an examiner of requisite expertise, for an addendum opinion. After a review of the record, the examiner should provide the following opinions: (a) Is it at least as likely as not (a 50 percent probability or greater) the Veteran's urethral disorder began during or is otherwise due to his active service? (b) Is it at least as likely as not (a 50 percent probability or greater) the Veteran's urethral disorder was caused or aggravated by one of his service-connected disabilities (to include treatment for these disabilities)? The examiner should address the Veteran's claim that he developed urethral stricture due to treatment to remove kidney stones, to include due to scarring. The examiner should address the 2005 examination which appeared to allude that TURP, cystoscopies, and venereal disease may cause stricture. The examiner must provide a complete rational for all opinions expressed. 2. After the above is complete, readjudicate the Veteran's claim. If a complete is not awarded, issue a supplemental statement of the case (SSOC) to the Veteran, and he should be given an opportunity to respond, before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on this matter. 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 2014). ______________________________________________ A. C. MACKENZIE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs