Citation Nr: 1804279 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 13-12 646 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected residuals of a herniated intervertebral disc and a mood disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Casey, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1970 to June 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In May 2015 and June 2017, the Board remanded the issue on appeal for further development. The directives have been substantially complied with and the matter again is before the Board. Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDING OF FACT The preponderance of the evidence of record is against a finding that the Veteran's erectile dysfunction is causally related to the Veteran's active service, or was caused or aggravated by a service-connected lumbar spine disability or mood disorder. CONCLUSION OF LAW The criteria for service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1101, 1110, 1154 (2012); 38 C.F.R. § 3.303, 3.304, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Legal Criteria Service connection may be granted 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006). Analysis The Veteran seeks service connection for erectile dysfunction, to include as secondary to residuals of a service-connected herniated intervertebral disc. The Veteran's available service treatment records do not show any symptoms, treatment, or diagnosis of erectile dysfunction while in service. Post-service, VA treatment records reflect that the Veteran has been diagnosed with erectile dysfunction since 2001. However, the medical records do not demonstrate that any medical professional has ever indicated that his erectile dysfunction either had its onset or may have been directly related to active duty service. Therefore, service connection is not warranted on a direct basis. A disability may also be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310 (a), (b). The question for the Board is whether the Veteran's erectile dysfunction is etiologically related to, or aggravated by, a service-connected disability. In May 2010, the Veteran underwent a VA examination to determine the nature and etiology of his condition. The examiner provided a diagnosis of erectile dysfunction but determined that it was less likely than not caused by or a result of the Veteran's lumbar spine disability. The examiner cited laboratory testing conducted in conjunction with the examination that revealed low testosterone levels, which caused erectile dysfunction. However, this same VA examination report also indicated that the most likely etiology of erectile dysfunction was alcoholism. In May 2015, the Board remanded this claim because the etiological opinion provided by the May 2010 VA examiner did not consider whether the erectile dysfunction may have been aggravated by the residuals of a herniated intervertebral disc, as required by 38 C.F.R. § 3.310. After a June 2015 examination, the VA examiner opined that it was less likely than not that the erectile dysfunction was caused or aggravated by the residuals of a herniated intervertebral disc, to include any medication prescribed for that condition. In reaching this conclusion, the examiner listed the factors that could contribute to erectile dysfunction and identified the factors that were present in the Veteran's case. The factors identified were "spine disease/medication, atherosclerosis, prior ethanol use, mental health medication to treat depression (Elavil), hypotestosteronism, and recent onset diabetes." The examiner then determined that the exact percentage contribution of each factor present could not be determined without resorting to mere speculation and, therefore, each factor should be considered as equally contributing. The examiner continued to explain that neurological effects of the lumbar spine disability were unlikely to cause the erectile dysfunction because of the anatomical location of the Veteran's nerve problems in his nervous system. The anatomical location of spinal nerves that could affect penile erection did not overlap with the anatomical location of the Veteran's affected spinal nerves. The examiner considered the effects of medication used to treat the lumbar spine disability, and while noting that narcotics could result in erectile dysfunction, determined that such causation could not be determined without resorting to mere speculation and the effects of the medications should be given equal weight as the Veteran's other factors. Lastly, the examiner considered whether there had been aggravation of the erectile dysfunction and found that there was no evidence of aggravation beyond its natural progression. In June 2017, the Board again remanded this claim for another etiological opinion. The Board found the June 2015 examiner to be contradictory when stating that multiple factors should be given equal weight in terms of contributing to the cause of erectile dysfunction, while at the same time finding that it is less likely than not that some of those same factors (the residuals of a herniated intervertebral disc and medication) caused the erectile dysfunction. Furthermore, the examiner's discussion on the contribution of each factor did not consider which factors were present at the time of the onset of erectile dysfunction. For example, the diabetes and medications for depression are more recent developments and the disability of atherosclerosis is not listed on the Veteran's problem lists. The Board also directed the VA examiner to consider the Veteran's contention that erectile dysfunction could be associated with the medications taken for the Veteran's service-connected mood disorder. Per the Board remand, the VA examiner provided an addendum report in June 2017. In this report, the VA examiner opined that the majority of the etiology of the Veteran's erectile dysfunction is more than likely caused by natural aging process, a history of smoking, diabetes mellitus, and hyperlipidemia. The examiner also opined that it was not at least as likely as not that the Veteran's service-connected mental disorder (or any other service-connected disability) caused or aggravated the Veteran's erectile dysfunction. The examiner reviewed the medical records associated with the file, including VA treatment reports. The examiner noted that the Veteran had intermittent impotence in April 2001 and that in January 2003, the Veteran reported that he no longer had erectile dysfunction, and his medication was discontinued. The examiner stated that this would suggest that the Veteran did not have a chronic erectile dysfunction disability until after January 2003. While the examiner noted that lumbar spine disease could cause erectile dysfunction, the evidence showed that the Veteran's back disability started in 1973. Given that there was no ongoing erectile dysfunction in January 2003, he found that it was unlikely that erectile dysfunction could be attributed to any significant degree to the back disability because the back condition was progressive and would not have improved between 2001 to 2003 to cause resolution in the erectile dysfunction. The examiner also noted that the Veteran's psychotropic medication could cause a side effect of ejaculatory inhibition. However, the examiner concluded that, had the Veteran's psychotropic medications been a significant factor, the medication prescribed for the Veteran's erectile dysfunction would not have been effective enough to remove or improve drug-induced ejaculatory inhibition. The VA examiner explained that, because the Veteran only required the medication intermittently to obtain an erection, could often obtain an erection without oral medication use, and there was no history of surgery or invasive treatments for erectile dysfunction, the evidence would not support that the Veteran's erectile dysfunction has been aggravated beyond normal progression by any service-connected disability. The Board finds the June 2017 VA examiner's opinion to be entitled to great probative weight. This opinion was provided by the same physician who examined the Veteran in June 2015, and after a review of the updated claims file. The examiner addressed the Veteran's assertions as to the origins of his erectile dysfunction, and the VA examiner provided an adequate rationale for the conclusions reached based on the record and the examination findings of record. Monzingo v. Shinseki, 26 Vet. App. 97 (2012) (examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion). There is no medical opinion to the contrary in the record concerning the etiology of the Veteran's erectile dysfunction. The Board acknowledges the Veteran's belief that his erectile dysfunction was caused or aggravated by residuals of a herniated disc or side-effects of psychotropic medication. The Veteran is competent to provide testimony concerning factual matters of which he has first-hand knowledge (i.e., experiencing symptoms either in service or after service). See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). However, as a layperson without the appropriate medical training and expertise, the Veteran is simply not competent to provide a probative opinion on a complex medical matter, such as an etiological relationship between any current disability and military service or a service-connected disability. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Based on the given facts, the preponderance of the evidence is against a finding that the Veteran's erectile dysfunction is etiologically related to or aggravated by his service-connected lumbar spine disability or by the side-effects of his medication for mood disorder. Thus, service connection for such cannot be granted. In sum, the Board finds that the preponderance of the evidence is against the Veteran's claim seeking service connection for erectile dysfunction. As the preponderance of the evidence weighs against the Veteran's claim, the benefit-of-the-doubt rule does not apply and the claim must be denied. 38 U.S.C. §5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for erectile dysfunction is denied. ____________________________________________ JENNIFER HWA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs