Citation Nr: 1803512 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 11-13 464 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to a rating in excess of 60 percent for fecal incontinence due to anal sphincter impairment associated with Crohn's disease. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Henry, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1969 to February 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2016 and June 2017, the Board remanded the claim for further development. FINDING OF FACT Resolving doubt in the Veteran's favor, his fecal incontinence more nearly approximates complete loss of sphincter control. CONCLUSION OF LAW The criteria for an evaluation of 100 percent for fecal incontinence have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.159, 4.1-4.14, 4.114, Diagnostic Code 7332 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Increased Rating A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, 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. Fecal incontinence is evaluated under 38 C.F.R. § 4.114, Diagnostic Code 7332, which evaluates rectum and anus, impairment of sphincter control. Under this diagnostic code, a 60 percent evaluation is warranted for extensive leakage and fairly frequent involuntary bowel movements. A 100 percent rating is warranted if there is complete loss of sphincter control. 38 C.F.R. § 4.114, Diagnostic Code 7332 (2017). The Veteran contends that his renal incontinence is more severe than the 60 percent rating depicts. See VA Form 9 entered in Caseflow Reader in May 2011. In August 2008, the Veteran was seen at the Chillicothe, OH VAMC. See Medical Treatment Record-Government Facility entered in Caseflow Reader in November 2008, p. 5. The Veteran stated that he had at least seven surgeries on his abdomen by which his rectal sphincter had been removed. The Veteran further stated that every night when he goes to sleep, he would lose sphincter control and had bowel movements all over the bed. This had been going on for several years and led to a divorce. See id. In January 2009, the Veteran saw a physician. See Medical Treatment Record-Non-Government Facility entered in Caseflow Reader in April 2016, p. 21. The examiner reviewed the claims file and performed an in-person examination. In October 2008, the Veteran lost significant weight due to his disabilities. The Veteran stated that he had problems with sphincter impairment since 1986 when he had a sphincterotomy. He had problems with urgency where he would have accidents if he could not get to the bathroom on time. During the night, the Veteran had no control. However, he did not use any absorbent material. He stated that he trained himself to make sure that he went to the bathroom when he had the urge so that he did not have any accidents. However, he stated that he would have to change his clothes about four to five times a week due to incontinence. The Veteran had leakage in between bathroom visits; however, he would just change his clothes at that time. He also did not sleep deep enough for fear of having accidents at night. Since his ileostomy, as the stool output was coming through the ileostomy, he did not have any incontinence problem. However, he was worried about having the incontinence problem again, once the ileostomy was reversed. The examiner noted that the Veteran had a lack of external sphincter pressure, decreased squeeze pressure of the internal anal sphincter. The Veteran had no relaxation of the internal anal sphincter. The examiner noted that the Veteran had significant fecal urgency with incontinence due to the fistulotomies and the anal sphincter impairment. See id. at 22-23. In July 2010, the Veteran was seen at the Columbus VAMC. See Medical Treatment Record-Government Facility entered in Caseflow Reader in July 2017, p. 44. The Veteran stated that he was having four to five stools during the daytime, mostly in the morning and one at night. See id. at 45. In October 2010, the Veteran was seen at the Columbus VAMC. See Medical Treatment Record-Government Facility entered in Caseflow Reader in March 2011, p. 2. The Veteran stated that he had six to ten stools per day including nocturnal stools. The Veteran stated that he occasionally had nocturnal incontinence. See id. In July 2011 and February 2012, the Veteran was seen at the Columbus VAMC. See Capri entered in Caseflow Reader in July 2016, p. 1 and 5. The Veteran was taking three loperamide a day for diarrhea; however, he was still having five to eight bowel movements per day during the day and two nocturnally that were loose. See id. at 1 and 5. In September 2016, the Veteran was seen by a physician who performed and/or interpreted an anal manometry. See Medical Treatment Record-Non-Government Facility entered in Caseflow Reader in October 2016, p. 3. The Veteran's pre and post-operative diagnosis was fecal incontinence. See id. The examiner noted that the Veteran had a history of fecal incontinence. The examiner further noted that the Veteran continued to have evidence of active disease and had been receiving Humira; however, he continued to report fecal incontinence. The incontinence episodes were fairly unpredictable. See id. at 4. Upon examination, the examiner noted that the Veteran had a reasonable squeeze although baseline coupled with squeeze pressures in combination was on the slightly low side, both subjectively and objectively. The pressures were low in the anterior-posterior direction. There were no immediate complications. See id. at 5. In July 2017, the Veteran was afforded a VA examination to determine the severity of his impairment of rectal sphincter control. The Veteran stated that he was taking loperamide two to three pills per day; however, he was still having involuntary bowel movements at night. The Veteran further noted that he had leakage on a regular basis. During the daytime, the Veteran had fecal incontinence seven to eight days per month of which he would have one to two episodes per day. He had five to nine diarrheal episodes per day; however, this number changed constantly. The Veteran did not wear pads; however, he changed his underwear whenever he had episodes. The Veteran stated that he had Crohn's disease flare ups about once per week and this sometimes increased his fecal incontinence. During the examination, the examiner did not note any anal scarring or fecal leakage. The examiner noted that the Veteran experienced extensive leakage with fairly frequent involuntary bowel movements. There were no external hemorrhoids. There was a small healing anal fissure. There were no other pertinent physical findings, complications, conditions, signs or symptoms related to the Veteran's fecal incontinence. The examiner noted that in September 2016, an anal manometry was performed on the Veteran. The results showed reasonable squeeze although the baseline coupled with squeeze pressures in combination was slightly low, both objectively and subjectively. The pressure was also low in the anterior-posterior direction. The examiner noted that the condition had an impact on the Veteran's ability to work, i.e., the Veteran would always have to be near and have access to a bathroom. The examiner confirmed the fecal incontinence diagnosis. The Board finds that the competent evidence of record reasonably supports the Veteran's claim that he suffers from a complete loss of sphincter control. The medical evidence of record documents a sphincterotomy in 1985 or 1986. The January 2009 examiner noted that the Veteran had decreased squeeze pressure of the internal anal sphincter which resulted in significant fecal urgency with incontinence. In 2016, an examiner noted that the Veteran had been prescribed Humira; however, he continued to have unpredictable fecal incontinence. The examiner found that the Veteran had reasonable squeeze although baseline coupled with squeeze pressures in combination was on the slightly low side, both subjectively and objectively. The pressures were low in the anterior-posterior direction. The Board notes that the July 2017 VA examiner noted that the Veteran experienced extensive leakage with fairly frequent involuntary bowel movements. However, resolving reasonable doubt in the Veteran's favor, the Board concludes that competent medical evidence, as well as the Veteran's competent and credible statements, support a finding that the Veteran's suffers from a complete loss of sphincter control. 38 C.F.R. § 4.7. ORDER Entitlement to a 100 percent rating for fecal incontinence due to anal sphincter impairment associated with Crohn's disease is granted. ____________________________________________ S. HENEKS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs