Citation Nr: 1632543 Decision Date: 08/16/16 Archive Date: 08/24/16 DOCKET NO. 04-24 916A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for urinary incontinence. ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran had active service from November 1965 to August 1968, which included a tour of duty in the Republic of Vietnam. The Veteran is in receipt of the Combat Infantryman Bade (CIB), among other awards and decorations. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2003 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Board initially denied the Veteran's claim of entitlement to service connection for urinary incontinence in June 2006. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In November 2007, the Court granted a Joint Motion for Remand (JMR) vacating the Board's decision and remanding for readjudication. The Board subsequently remanded the Veteran's claim for additional development in October 2008, November 2009, and November 2012. Such now returns to the Board for final appellate review. In addition to the urinary incontinence issue, the November 2012 Board determination also remanded the issue of entitlement to TDIU. The Board concludes that this issue is no longer in appellate status. By way of background, a July 2012 Supplemental Statement of the Case (SSOC) concluded that entitlement to TDIU was not warranted prior to June 4, 2012, and that entitlement to TDIU after that date was moot in light of the assignment of a 100 percent schedular rating for posttraumatic stress disorder (PTSD). Thereafter, in November 2012, the Board remanded the issue of entitlement to TDIU for the issuance of an SSOC based on the grant therein of an increased rating of 70 percent for PTSD prior to June 4, 2012. The Board determination did not limit the period of entitlement to TDIU to the period prior to June 4, 2012, or otherwise discuss the RO's assertion that the issue of entitlement to TDIU from June 4, 2012, was moot. In a January 2013 rating decision, the RO granted entitlement to TDIU from May 14, 2003, to June 4, 2012 (at which time he had a 100 percent schedular rating). The RO considered this determination to be a complete grant of the benefits with respect to the TDIU issue and the Veteran's then-attorney representative agreed, as in correspondence she specifically noted that no further appeal of that issue was warranted. Although the Board is cognizant of the holdings in Bradley v. Peake, 22 Vet. App. 280 (2008) and Buie v. Shinseki, 24 Vet. App. 242 (2011) regarding whether the issue of TDIU is moot in cases where a schedular 100 percent rating is in effect, given that the Veteran has not expressed disagreement with the above determination with respect to the award of entitlement to TDIU and effective dates assigned, the Board concludes that the issue is no longer in appellate status. This appeal was processed using the Veteran's Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran's urinary incontinence and related symptoms were incurred in service, are otherwise related to his military service, or were caused or aggravated by a service-connected disability. CONCLUSION OF LAW Service connection for urinary incontinence is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2006), (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Such notice applies to all five elements of a service connection claim, to 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the instant case, VA's duty to notify was satisfied by a letter in April 2002 specifically addressing his claim for service connection for urinary incontinence, as well as numerous subsequent letters that provided general information as to the information necessary to establish entitlement to service connection. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Furthermore, to the extent that the Veteran was not provided notice of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra, the Board finds no prejudice in proceeding with a decision regarding the Veteran's service connection claim. In this regard, as the Board concludes herein that the preponderance of the evidence is against the Veteran's claim, any questions as to the appropriate disability rating or effective date to be assigned are rendered moot. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. §§§ 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In the instant case, the Board finds that all relevant facts have been properly developed and that all evidence necessary for equitable resolution of the issues decided herein has been obtained. The Veteran's service treatment records, post-service VA and private treatment records, and Social Security Administration (SSA) records have been obtained and considered. He has not identified any additional, outstanding records that have not been requested or obtained. Furthermore, multiple VA examinations are of record, the most recent being in April 2009. Several addenda opinions to that examination report also have been obtained, most recently in July 2014. The Board concludes the examination report and addenda in this case are adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Based on the association of VA treatment records, the April 2009 VA examination report and addenda, and the subsequent readjudication of the claim, the Board finds that there has been substantial compliance with its prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In light of the foregoing, the Board finds that VA's duties to notify and assist have been satisfied. Thus, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Analysis Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection generally requires evidence satisfying three criteria: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In the instant case, as urinary incontinence is not considered a chronic disease per VA regulations, the laws governing presumptive service connection, to include those pertaining to continuity of symptomatology, are inapplicable. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that the provisions of 38 C.F.R. § 3.310 were amended during the pendency of the Veteran's appeal, effective October 10, 2006; however, the new provisions state that service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). Although the stated intent of the change was merely to implement the requirements of Allen, supra, the Board finds that the new provisions amount to a substantive change to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the Veteran as it does not require the establishment of a baseline level of disability before an award of service connection may granted. See generally, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contends that he has urinary frequency, incontinence, and similar symptoms that began during service in approximately 1966, worsened during his period of service in Vietnam due to the unsanitary conditions there, and continued after service until the symptomatology worsened in 1983 as a result of a workplace injury. He also has advanced the theory that an in-service incident involving a multiple day loss of consciousness contributed to the urological problems. In addition, the medical evidence has suggested that the Veteran's service-connected diabetes mellitus might have caused or aggravated the urinary incontinence and other symptoms, although the Veteran currently does not contend that the diabetes was a factor in his current urinary symptoms. The Veteran's service treatment records include an August 1966 diagnosis of acute urethritis. In September 1966, he had urethral discharge and was diagnosed with non-gonococcal urethritis. In March 1967, the Veteran had thick, yellow urethral discharge and his wife had vaginitis. The diagnosis was urethritis. A July 1967 service treatment record included complaints of a 16 to 18 month history of recurrent non-specific urethritis. In August 1967, the Veteran had experienced urethral discharge for the previous three days and was referred to the venereal disease clinic. In July 1968, the Veteran had painful urination. His August 1968 separation examination was normal. Shortly after service, later in August 1968, the Veteran was advised that due to his recurrent episodes of urethritis he should have a meatotomy and circumcision and he underwent those procedures later that month. At that time, the Veteran's chief complaint was chronic urethral discharge and intermittent paraphimosis. In September 1968, the Veteran reported that in November 1967 he had received a concussive trauma and been unconscious for two days. He convalesced for two weeks and since that time had experienced monthly "crushing" headaches with associated dizzy spells. The Veteran reported no urological problems due to the incident and examination did not show any such problems. In August 1979, the Veteran reported a one-month history of urinary frequency, both night and day, but without dysuria, burning, or penile discharge. No diagnosis was provided, and no opinion was given as to etiology. In November 1983, the Veteran was hospitalized after having fallen a number of stories while working on a construction project. Injuries included multiple fractures to the hip and pelvis. Following reduction and internal fixation of the left hip, the Veteran was examined in urology in consultation for hematuria. He was found to have a renal contusion, but also had difficulty voiding. He underwent urodynamic tests, the results of which were felt to be consistent with elements of neurogenic bladder. Medical records from 1983 to 1986 show consistent treatment, testing, and surgical investigation involving complaints of urinary retention, urinary frequency, and bladder problems. In November 1983, the Veteran reported a long history of difficulty urinating with frequency and urgency, as well as post-void dribbling. Another November 1983 medical treatment record, by contrast, indicated that, prior to the accident, the Veteran had "no voiding dysfunction." In addition, there was a recent history of pelvic trauma. Testing showed a small capacity bladder with bladder outlet obstruction, blunting and dilation of the right upper pole calyces, and a distended bladder secondary to a large residual. A February 1984 surgical note attributed urinary hesitancy to the 1983 accident. In March 1985, the Veteran complained of urinary frequency, day and night, without dysuria or slowing of his urinary stream. In April 1985, he had urinary frequency of unknown etiology. He voided every hour, had to get up four times per night, and had terminal dribbling. The physician noted that the Veteran had no known diabetes, psychiatric, or neurological disorders. In November 1986, the Veteran underwent a cystoscopy due to the urinary frequency, with normal findings other than chronic inflammation of the bladder. He reported voiding every 15 to 20 minutes during the day and sometimes at night. The stream was very weak and he had hesitancy and straining to void. He denied stress or urgency incontinence. A January 1987 psychological report included the Veteran's denial of medical problems prior to his 1983 workplace accident, other than a fractured arm without ongoing problems. He reported current urinary frequency problems and soiling of clothes, indicating that his bladder "is messing up." In September 1990, a physician concluded that the Veteran suffered from severe genitourinary dysfunction (including urinary frequency and loss of bladder control) secondary to a fractured pelvis with intrapelvic trauma from the 1983 fall. January 1991 testimony by the same physician as part of a lawsuit involving the 1983 accident indicated that the Veteran, "had severe genitourinary dysfunction, secondary to a fractured pelvis with intrapelvic trauma." The physician went on to explain, "a neurogenic bladder is one that you will see after a person has a spinal cord injury where the bladder becomes - they maybe have bladder outlet obstruction, distention of the bladder; and then as time goes on, the distention of the bladder eventually destroys the tone of the muscles in the bladder from over-distention. As times goes on, these people have maybe chronic infections in their bladder, what we call chronic cystitis; and as time goes on, they will maybe develop a contracture of the bladder." The physician noted that, with respect to the 1983 accident, "all of these fractures and deformities of the pelvis actually are very close to the bladder." The physician attributed the following urinary symptoms to the Veteran's 1983 injury: "[a]n inability to void, constantly going to the bathroom, soiling his pants, constant pressure on [the] bladder, and constant daily pain in [the] back." The physician believed that the Veteran would experience ongoing intermittent bladder infections, chronic cystitis, urinary frequency, and dribbling. In February 1991, the Veteran submitted a statement to VA regarding his urinary frequency/incontinence. Specifically, he reported that, in about 1966, his first wife developed a urinary tract infection and the Veteran also was treated because he had discharge from his penis. The symptoms cleared up in one day with medication, but he periodically developed an infection while in Vietnam due to the unsanitary conditions. The Veteran eventually learned that the infections were because he was uncircumcised and he underwent a circumcision in 1968. Subsequently, in about 1977 or 1978 he became allergic to his wife's douche and VA medical professionals, after testing, advised his wife to change her douche powder and "everything cleared up." There were no follow-up visits and the Veteran did not otherwise report ongoing urinary symptoms from service. In September 1996, the Veteran reported urinary frequency with urgency, decreased stream, and dribbling since surgeries in 1983. In January and March 2001, the Veteran reported problems with urinary frequency. The Veteran was afforded a VA examination in March 2003. The examiner noted that the Veteran was a very poor historian, with a poor memory. He reported ongoing problems with his bladder and urinary tract after separation from service and underwent seven surgical procedures between November 1983 and 1990. His current condition resulted in severe frequency and urgency of urination. If there was any delay in reaching a bathroom the Veteran stated that he would wet his pants. The incontinence occurred about twice per day and he had used adult diapers in the past, although not presently. The Veteran understood that he had a small bladder that emptied frequently. The examiner was unable to reach a conclusion regarding the etiology of the urinary incontinence because the service treatment records were not available for review. A July 2003 VA treatment record noted urinary incontinence. The Veteran complained of voiding in small amounts and urinary retention. However, in March 2004, he denied any genitourinary difficulties. Another March 2004 VA treatment record, by contrast, indicated urinary incontinence with recurrent episodes of nocturia and increased hesitancy. In February 2006, the Veteran was noted to have no urinary complaints. In addition, he denied painful or burning urination. In August 2006, however, he was discouraged about his ongoing urinary incontinence. In October 2006, the Veteran reported occasional urinary incontinence for a long time and that he wore a diaper. In November 2006, a psychiatry note stated that he was dealing with urinary incontinence. In April 2007, the Veteran reported urinary incontinence, for which he wore adult diapers during the daytime. In another April 2007 record, he reported urinary incontinence for a long time. In May 2007, the Veteran reported voiding with difficulty. A September 2007 private hospitalization record, however, indicated that the Veteran had no urinary complaints and the records did not indicate the need for or use of adult diapers during his hospitalization. An April 2009 VA urological examination report noted that the Veteran was treated for gonorrheal urethritis in service apparently without any complications, but was found to have a small urethral meatus. Shortly after service, he developed paraphimosis and underwent a circumcision and meatotomy. The Veteran reported that he had been incontinent ever since. The examiner, however, indicated that "in reviewing as much as I possibly could in my limited exposure of his large record I find no mention of incontinence throughout the entire chart until very recently.... Of great significance is the fact that he had an industrial work accident in 1983, was rendered unconscious, had a fractured pelvis and hip, was in the hospital for quite some time, underwent a number of surgeries, and at that time had a full evaluation urologically to be sure his urinary system was intact." Multiple urological studies at that time were normal, but after release from the hospital began to complain of urinary frequency. The examiner acknowledged the Veteran's current complaints of urinary frequency that developed or worsened due to living conditions in service, but the examiner found those reports inconsistent with the contemporaneous medical evidence. The Veteran's description of his symptoms was more akin to urinary frequency than incontinence. He was wearing a diaper that was totally dry. The examiner concluded, "[t]here is no correlation between the urethral meatus and incontinence and in fact there is no sphincter activity anywhere near the urethral meatus and I do not see how this procedure could cause any type of incontinence. As far as difficulty with the bladder goes, I certainly think there is cause for him to have some scarring and some injury to the soft tissue [of] his pelvis with his accident in 1983 and on top of that he is diabetic and takes oral medications and is somewhat overweight. So in essence, I cannot relate his urinary difficulties, which I must say at this point are all subjective, to the meatotomy done some 40 years ago." In a May 2009 statement, the Veteran discussed how he had tried to explain to the VA examiner that the living conditions in Vietnam contributed to his urinary problems and that he had experienced urinary problems and pain while in Vietnam. The problems continued after returning home and he had sought help then. He discussed problems beginning in 1966 at Fort Bragg, including painful discharge that was yellow, white, brown, and/or green; itching; burning; and spots of blood. He had problems with leakage and soiling of his pants. He claimed to have been diagnosed with chronic urethritis, urinary frequency, and other genital problems. He was recommended to have a meatotomy, which he did. The Veteran acknowledged that the 1983 accident aggravated the urinary condition, but that did not account for the in-service problems. He also believed that an in-service head injury where he was "thrown quite a distance into a ravine" also contributed to the urinary problems. The Veteran described ongoing symptoms of uncontrolled, urgent, weak flow, and/or painful urination, leakage, and split streams. A May 2012 VA examination report for diabetes mellitus did not attribute any urological symptoms, including urinary frequency / incontinence, to the diagnosed diabetes mellitus. A May 2012 VA addendum opinion to the April 2009 VA examination report noted that the original VA examiner who had conducted the urology examination had died. The reviewing medical professional noted that the Veteran was treated in service on multiple occasions for gonococcal urethritis and non-specific urethritis. At that time, the Veteran was found to have a tight penile frenulum and a small urethral meatus. A circumcision and urethral meatotomy was performed shortly after separation from service. In 1983, the Veteran reported that he had become incontinent after he circumcision and meatotomy, but urologic evaluation did not demonstrate any significant abnormality. The reviewing medical professional opined that it was unlikely that the incontinence was caused by the in-service urethritis, the treatment for urethritis, the circumcision, or the urethral meatotomy. The rationale was that there were no symptoms/residuals related to the Veteran's service-connected meatotomy. A July 2014 VA addendum opinion concluded that it was less likely than not that the Veteran's urinary frequency was proximately due to or the result of his service-connected disabilities. Specifically, there were documented urinary complaints of frequency and incontinence since 1983 (at which time significant pelvic and bladder trauma was reported). Prior urology notes noted that no issues had been described prior to that timeframe. As to the diabetes mellitus, first diagnosed in 2007, he remained well-controlled on oral medication and no change in voiding patterns had been described since diagnosis. Moreover, there was more than a 20 year time lag between the bladder trauma and the diabetes diagnosis without documented symptom changes. As such, no cause or aggravation due to the diabetes was identified. In a February 2015 statement, the Veteran stated that his urinary frequency problems started back in 1966 while stationed at Fort Bragg, North Carolina. The problems continued through his tour in Vietnam and actually worsened due to the unsanitary conditions in the jungles and swamps, such as mud and unclean water. He continued to have problems after Vietnam and pursued treatment at the VA hospital and received surgery for the problem. The 1983 post-service injury might have aggravated the problem, but did not cause the problems with urinary frequency. Having reviewed the complete record, the Board concludes that the preponderance of the evidence is against finding that the Veteran's urinary frequency, incontinence, and related symptoms were incurred in or are otherwise related to service or were caused or aggravated by a service-connected disability (including his meatotomy and diabetes mellitus). In reaching that conclusion, the Board has considered the Veteran's representations that urinary frequency symptoms began in 1966, worsened during service in Vietnam, and continued after service, before increasing as a result of his 1983 workplace accident. The Board finds these allegations less than credible. Credibility is an adjudicative and not a medical determination. The Board has "the authority to discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In this case, the "inherent characteristics" of the Veteran's current statements as to the onset and ongoing nature of urinary frequency and incontinence symptoms from 1966 are inconsistent with the objective medical record. As noted above, the service treatment records document ongoing diagnoses of urethritis with penile discharge during service; however, this "discharge" was not urine. There were no reports or complaints of urinary frequency or incontinence. Rather, the Veteran had penile discharge due to urethritis, which was treated and corrected with medication. The underlying cause of the chronic urethritis was a narrow urinary foramen, which was corrected through a meatotomy immediately after service (and for which the Veteran is service-connected). The record includes no complaints of urinary frequency or incontinence until August 1979, at which time the Veteran reported only a one-month history of urinary frequency and similar symptoms. The Board finds that, had the Veteran been experiencing ongoing urinary frequency, incontinence, or similar symptoms since service, he would have reported such ongoing symptoms at the time of initial treatment, rather than reporting only a one-month history of such problems. The Board's conclusion that the Veteran's current representations of ongoing urinary frequency and/or incontinence from service are not credible is supported by additional contemporaneous evidence. For example, during a January 1987 psychological evaluation the Veteran denied medical problems prior to his 1983 workplace accident, other than a fractured arm as a child. In a February 1991 statement, in discussion of his claim for "urinary frequency" the Veteran never actually described any urinary frequency in service or for years after service. Instead, he discussed penile discharge and other acute problems that were treated and resolved with medication and changing his first wife's douche. He did not discuss any in-service urinary frequency or any urological symptoms that were chronic and not addressed by medication, surgery, or changes in feminine hygiene products. Finally, a September 1996 private treatment record documented the Veteran's report that urinary frequency and similar symptoms had been present since 1983. In light of all the foregoing, the Board finds the Veteran's current representations as to ongoing urinary frequency, incontinence, and similar problems since service to be less than credible. In reaching that conclusion, the Board acknowledges the November 1983 private treatment record in which the Veteran reported a long history of urinary frequency and associated problems. The Board finds this document of limited probative value, however, given that another November 1983 private treatment record specifically indicated that the Veteran had no voiding dysfunction prior to the 1983 workplace accident. Given these conflicting near contemporaneous reports and the multiple records both prior and subsequent to November 1983 denying ongoing urinary problems, the Board affords the November 1983 conflicting reports little probative weight. In any case, the long history of urinary frequency referenced could date back to 1979, when the Veteran first reported onset of urinary frequency and the long history referenced does not specifically support a finding of symptomatology from service. The Board also has considered the case of Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), wherein the Court held that the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. However, this is not a case in which the record is merely silent regarding whether the Veteran had ongoing urinary symptoms from 1966. Rather, the Veteran denied any such ongoing problems on multiple occasions to health care providers in the years prior to filing his current claim for VA compensation benefits. Regardless of whether the Veteran is purposely mischaracterizing the events in service and the years thereafter or unintentionally doing so, the ultimate conclusion is that any current statements regarding the incurrence of urinary frequency, incontinence, and similar symptoms in service and continuing thereafter are not credible evidence. No medical professional has opined that the Veteran's urinary frequency, incontinence, or similar symptoms were incurred in or are otherwise related to military service, including his claimed injury resulting in multiple days of unconsciousness. Indeed, there are multiple private and VA medical opinions to the contrary. With respect to whether the current urinary frequency, incontinence, and other symptoms were caused or aggravated by a service-connected disease or injury (specifically residuals of the meatotomy and diabetes mellitus), the Board notes that the Veteran in his most recent statements has specifically argued that his urinary symptoms are unrelated to any of his service-connected disabilities and has adamantly argued that the symptoms began in service and are directly related to service. As discussed above, the Board does not find these contentions credible. Nevertheless, given that medical evidence suggested a possible association between a service-connected disability and service medical opinion were obtained regarding any link between the urinary symptoms and a service-connected disability. The April 2009 VA examiner considered whether the Veteran's urinary symptoms were related to his service-connected meatotomy, but concluded that they were not. The rationale was that the claims file did not include any evidence to support the contentions raised by the Veteran during the examination that he had experienced ongoing urinary frequency and other symptoms since the 1968 meatotomy. (The Board also finds such contentions by the Veteran less than credible for the reasons discussed above regarding his initial report of a one-month history of urinary frequency in August 1979 (i.e., more than 10 years after his meatotomy) and the multiple denials of ongoing urinary symptoms prior to his 1983 workplace accident.) The examiner stated that there was no medical basis for believing that a meatotomy would result in urinary problems such as incontinence. Specifically, he stated that, "[t]here is no correlation between the urethral meatus and incontinence and in fact there is no sphincter activity anywhere near the urethral meatus and I do not see how this procedure could cause any type of incontinence." Instead, the examiner attributed the Veteran's current urinary problems to his post-service 1983 workplace accident, based on the nature of the injury, the Veteran's reported symptoms, and the medical findings and treatment for the symptoms. In context, the Board finds that the above opinion contemplates both causation and aggravation, as the examiner found that all the symptoms were attributable to factors other than the meatotomy. These findings were supported by the May 2012 VA examination report addendum, which also concluded that it was unlikely that the incontinence was caused by the in-service urethritis, the treatment for urethritis, or the post-service circumcision and/or urethral meatotomy. The Board finds the above opinions the most probative evidence of record regarding the relationship between the service-connected meatotomy and his urinary symptoms. That said, the April 2009 examiner did note that the Veteran had diabetes mellitus, which was interpreted as suggesting a possible link between the diabetes mellitus (which was subsequently service-connected) and the urinary symptoms. The July 2014 VA examination report addendum, however, concluded that the urinary frequency/incontinence symptoms were not proximately due to or the result of the Veteran's service-connected diabetes mellitus. The rationale was that he was diagnosed with diabetes mellitus in 2007 and the disability remained well-controlled on oral medication and without reported changes in voiding patterns since diagnosis and treatment. There was a more than 20 year time lag between bladder trauma and diabetes mellitus onset without documented symptom changes and, as such, no cause or aggravation due to the diabetes mellitus was identified. The Board finds the above opinion the most probative of the evidence of record regarding the possible association between the diabetes mellitus and the urinary frequency, incontinence, and other symptoms, as the opinion was based on review of the Veteran's representations and the medical evidence of record, with a thorough rationale provided for the opinion given. In conclusion, the most probative evidence of record indicates that the Veteran's current urinary frequency, incontinence, and other symptoms were not incurred in service, are not otherwise shown to be related to service, and were not caused or aggravated by his service-connected meatotomy or diabetes mellitus. As discussed, the Board finds the April 2009 VA examination report and May 2012 addendum of significant probative value regarding the potential relationship between the service-connected meatotomy and the urinary symptoms and the July 2014 addendum opinion the most probative evidence regarding any potential relationship between the service-connected diabetes mellitus and the urinary symptoms. The Board finds the Veteran's statements regarding the onset and continuity of urinary symptoms from 1966 to be less than credible and there is no medical evidence suggesting a link between the urinary symptoms and service. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim for service connection must be denied. See 38 U.S.C.A. § 5107(b) (West 2014); see generally Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). ORDER Service connection for urinary incontinence is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs