Citation Nr: 1804677 Decision Date: 01/24/18 Archive Date: 02/05/18 DOCKET NO. 10-22 587A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for sleep apnea. 2. Entitlement to service connection for sexual dysfunction including erectile dysfunction ATTORNEY FOR THE BOARD Robert A. Elliott II, Associate Counsel INTRODUCTION The Veteran had active service from February 1976 to July 2000. This appeal comes before the Board of Veterans 'Appeals (Board) from a March 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This matter was previously before the Board in October 2014 and May 2017, at which time it was remanded for additional development. In May 2017, the Board remanded the Veteran's claim for further development. The agency of original jurisdiction (AOJ) substantially complied with the May 2017 remand directives, and no further development is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. The Veteran's sleep apnea is not shown to be causally or etiologically related to any disease, injury, or incident during service. 2. The Veteran's sexual dysfunction is not shown to be causally or etiologically related to any disease, injury, or incident during service, and is not caused or aggravated by medication for his service-connected hypertension. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea are not met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2012); 38 C.F.R. § 3.303, (2017). 2. The criteria for service connection for sexual dysfunction including erectile dysfunction are not met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2012); 38 C.F.R. § 3.303, (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA's duty to notify was satisfied for the claim before the Board by letter dated May 2008. See 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). The record also reflects that VA has made efforts to assist the Veteran in the development of his claim. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records (STRs), VA medical records, private medical records, VA examination reports, and the statements of the Veteran. II. Service Connection In order to obtain service connection (under 38 U.S.C. §§ 1110, 1131 and 38 C.F.R. § 3.303), the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, i.e., a "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 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. See 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). The competence, credibility, and probative (relative) weight of evidence, including lay evidence must be assessed. See generally 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the unique and readily identifiable features of a medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A. Sleep Apnea The Veteran asserts that his currently diagnosed sleep apnea was incurred during service. Service treatment records are silent as to any complaints of or treatment for sleep apnea. However, service treatment records indicated that the Veteran participated in a weight management program. A January 1996 nutritional assessment noted that he recently gained 20 lbs. and was overweight or obese. A September 1998 record showed that he was clinically obese, had a neck size of 16.5, and a body mass index of 30. In October 1999, the Veteran weighed 229 lbs. In December 1999, the Veteran weighed 233 lbs., had a neck size of 17.25, and a body mass index of 33. In April 2000, he was found to be mildly obese. The Veteran submitted a January 2011 buddy statement from his ex-wife indicating that during their marriage from 1975 to 1980, the Veteran snored loudly, did not sleep well, and had difficulty getting up early in the morning. April 2008 and July 2014 sleep studies were positive for obstructive sleep apnea (OSA). The April 2014 sleep study indicated that the Veteran's body mass index was 39.4 and his neck circumference was 19.5 inches. The Veteran was afforded a VA examination in February 2016. The examiner noted the Veteran's diagnosis of obstructive sleep apnea. He reported that his physician ordered asleep study due to tiredness, snoring, and breathing difficulties at night. The examiner opined that his sleep apnea was not related to service and gave the following rationale: [S]noring is not pathognomonic of an existent condition.... The preponderance of medical evidence and expertise reveals the proximate cause of [obstructive sleep apnea] to be a developmentally narrow oropharyngeal airway, often with superimposed elevation of [body mass index] (creating encroachment of airway with fatty soft tissues) -currently at morbid level, and/or natural aging (encroachment of airway with floppy soft tissues) -neck circumference of 20 inches. The examiner then referenced medical literature for the finding that snoring was a common feature of obstructive sleep apnea and associated with a sensitivity of 80 to 90 percent for the diagnosis of obstructive sleep apnea, but its specificity was below 50 percent. The examiner also found that people with mild snoring and a body mass index lower than 26 were unlikely to have moderate or severe obstructive sleep apnea. Finally, the examiner found that obstructive sleep apnea was prominent among men with a collar size greater than 17 inches. In a July 2016 addendum opinion, the examiner opined that isolated documentation of elevated blood pressure and being overweight was not evidence of obstructive sleep apnea being present, but only components of a more complex puzzle. The examiner then stated that a "problem sleeping" did not indicate that obstructive sleep apnea existed because usually obstructive sleep apnea patients wanted more sleep. In July 2017, as required by the May 2017 Board Decision, an addendum VA medical opinion was provided. The examiner opined that the Veteran's sleep apnea was less likely than not incurred in, caused by or otherwise etiologically related to (the) sleep issues during active duty service. The rationale stated was: Despite service treatment records (STR's) showing weight gain, increase in his neck circumference and the Veteran's participation in a weight management program, it is silent for symptoms, complaints, diagnosis, management or treatment of OSA and/or residuals. 1996-2000 STR Veteran weight ranged 225-233 lbs. April 2000 STR Retirement Physical is silent for OSA and/or residuals (weight 230 lbs.) STR. Weight gain without subjective complaints or objective evidence with testing is not consistent with OSA. Immediate post-service medical records are silent for symptoms or diagnosis of OSA. OSA is diagnosed by April 2008 & August 2014 Sleep Studies (8-14 years post-service) OSA is most likely due to further incremental weight gain post-service (not aggravated beyond its natural progression due to military service.) 2007-2009 Weight range 245-275 (15-45 lbs. weight gain post-service) June 2014 Weight is 295lbs, 2 months prior to sleep study (65lbs weight gain post-service). Concur with Feb 2016 C&P Examiner. "UpToDate" Literature review current through Dec 2016 regarding "Obstructive Sleep Apnea in Adults" reports: Obstructive sleep apnea is the most common sleep-related breathing disorder. The estimated prevalence in North America is approximately 20 to 30 percent in males and 10 to 15 percent in females. OSA is a disorder that is characterized by obstructive apneas and hypopneas caused by repetitive collapse of the upper airway during sleep. The diagnosis should be considered whenever a patient presents with symptoms such as excessive daytime sleepiness, snoring, and choking or gasping during sleep, particularly in the presence of risk factors. The important risk factors for OSA are advancing age, male gender, obesity and craniofacial or upper airway soft tissue abnormalities. Additional risk factors identified in some studies include smoking and family history. The Board finds that the July 2017 addendum opinion is the most probative evidence. The examiner considered the history in detail, and provided a definitive opinion that was adequately supported by rationale. The opinions were accompanied by a rationale for the conclusion reached, and specifically discussed related VA examinations included in the record including medical references. Accordingly, it is given great probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-4 (2008). Based on a review of the evidence, the Board finds the preponderance of the lay and medical evidence to be against a finding that sleep apnea manifested in service or within the first post-service year, or that such disability is otherwise etiologically related to service. The record does not indicate a complaint regarding sleep apnea during active duty service. Further, medical records submitted indicate the Veteran was not diagnosed with sleep apnea until 2008, many years after service. In addition, while the Board notes the record regarding the Veteran's weight gain throughout service, Weight gain without subjective complaints or objective evidence with testing is not consistent with OSA as noted by the July 2017 medical opinion. In sum, the evidence deemed most probative by the Board demonstrates that the Veteran's sleep apnea did not manifest in service, or indeed for many years thereafter. Furthermore, the most probative evidence establishes that his sleep apnea is unrelated to service, and was not caused or aggravated by a service-connected disability. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Sexual dysfunction including erectile dysfunction The Veteran contends that he has sexual dysfunction, including decreased sexual drive, problems with orgasm, and ED. He states that these dysfunctions began after changes in medication for his service-connected hypertension, thus contending that the dysfunctions are secondary to the service-connected hypertension. See October 2014 Board remand. Service treatment records are silent as to any complaints of or treatment for sexual dysfunction including erectile dysfunction. In March 2009, the Veteran attended a VA Genitourinary Examination. The Veteran complained of difficulty having an orgasm, but could achieve and maintain an erection. He also reported that he could achieve vaginal penetration, a history of bladder infections, complaints of urinary straining, blood in his urine, urinary retention, fatigue, and retrograde ejaculations. After examination, the examiner noted normal penis and testicles. A diagnosis of anorgasmia/low testosterone was made. The examiner opined that the etiology of the Veteran's erectile dysfunction cannot be determined without mere speculation because it is likely multifactorial in nature. Further, the examiner explains that he has multiple medical conditions and medications that could cause his anorgasmia (lack of orgasm) that include both non service-connected age, history of smoking, obesity, anxiety, and anti-depressant/ anxiety medications as well as his service-connected hypertension and medication. In February 2016, as required by the October 2014 Board remand, a VA addendum medical opinion was provided. The Veteran reported that he submitted a claim for his inability to ejaculate and not a deformity. He reported 1 out of 10 times he is unable to neither reach orgasm nor ejaculate. He reported that his primary care doctor told him this is due to his cardiac medications, although no referral to urologist/ studies were performed. Veteran takes no medications for this issue. Upon examination, the examiner noted that the Veteran did not have erectile dysfunction or retrograde ejaculation. The examiner noted normal penis and testicles. Further, the examiner opined that the Veteran's anejaculation was not caused by service or a service connected condition. In addition, he notes that the Veteran's condition was not caused by hypertension, nor aggravated by hypertension in any measurable way. Condition is less likely than not secondary to Celexa (not a cardiac medication) usage (less than 6% chances). Condition most likely than not age related as supported by medical literature. In a July 2016 Addendum opinion, the examiner notes that Toprol FDA profile indicated that erectile dysfunction was identified in less than one percent of patients taking the medication and that there were no reports of anejaculation in patients using the medication. In July 2017, as required by the May 2017 Board Decision, an addendum VA medical opinion was provided. The examiner noted "service treatment records (STRs) reviewed, including April STR 2000 Retirement Physical were silent for diagnosis, management or treatment of sexual dysfunction, including ED, ejaculatory dysfunction and/or residuals. (Hypertension treatment with Lotensin during separation). Immediate post-service medical records are silent for diagnosis, management or treatment of sexual dysfunction, including ED, ejaculatory dysfunction and/or residuals." He also noted "During this Compensation and Pension examination no subjective ED reported by Veteran." Further, the examiner opined "It is less likely than not caused by, did not originate during and is not otherwise etiologically or causally related to his active period of military service. As rationale for the July 2017 medical opinion, the VA examiner indicated that the "Entire STR, including April 2000 Retirement Physical are silent for ED, and Immediate post-service medical records are silent for ED." He also noted the claimed condition was first diagnosed in March 2009, which is 9 years post-service. Regarding the issue of secondary service connection, via causation or aggravation by an already service-connected condition or for treatment therefore, he opined "It is less likely than not caused or permanently worsened by his hypertension or hypertension medications." As rationale, the examiner indicated "Having carefully considered (1) the Veteran's long history of hypertension medication (including Lotensin and Toprol XL), (2)the Veteran's statements that his sexual dysfunction symptoms dated to when he switched to Toprol; (3) and the March 2009 and February2012 VA examiner's statements, it this Compensation and Pension Examiner's professional opinion[that]"Review of Evidence-based drug-induced sexual dysfunction literature indicates that although certain anti-hypertensive medications can result in sexual dysfunction, the Veteran's medications (Toprol XL and Lotensin) are not implicated as risk factors. SSRI's (e.g. Celexa) are associated with decreased libido, delayed orgasm or ejaculation, and anorgasmia. The examiner also noted concurrence with the February2012 VA medical examiner's opinion that the "Veteran's multiple risk factors for sexual dysfunction (ejaculatory dysfunction)-include longstanding smoking history x20-22years, natural aging > 50yrs, Hypogonadism (consider Urologic evaluation for testicular atrophy), SSRI medication Celexa, Anxiety disorder (Rx with Alprazolam) and partner relational issues. Extrapolating above risk factors makes Ejaculatory Dysfunction less likely than not due to service connected hypertension or hypertension medications. The Board finds that the July 2017 addendum opinion is the most probative evidence. The examiner considered the history in detail, and provided a definitive opinion that was adequately supported by rationale. The opinions were accompanied by a rationale for the conclusion reached, and specifically discussed related VA examinations included in the record including medical references. Accordingly, it is given great probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-4 (2008). Based on a review of the evidence, the Board finds the preponderance of the lay and medical evidence to be against a finding that sexual dysfunction manifested in service or within the first post-service year, or that such disability is otherwise etiologically related to service. The record does not indicate a complaint regarding sexual dysfunction during active duty service. Further, medical records submitted indicate the Veteran was not diagnosed with sexual dysfunction until 2009, many years after service. In addition, the evidence of record does not support a finding that the Veteran's medication for his service-connected hypertension caused or aggravated his sexual dysfunction. Namely, the July 2017 addendum medical opinion notes that the Veteran's medication had not been found to be risk factors for sexual dysfunction. The Board has also considered the Veteran's lay statements that his sexual dysfunction was caused by his hypertension medication. While the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to a medical connection between his service-connected hypertension's medication and his sexual dysfunction. In sum, the evidence deemed most probative by the Board demonstrates that the Veteran's sexual dysfunction did not manifest in service, or indeed for many years thereafter. Furthermore, the most probative evidence establishes that his sleep apnea is unrelated to service, and was not caused or aggravated by a service-connected disability or any medications prescribed for service-connected disabilities. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (CONTINUED ON NEXT PAGE) ORDER Service connection for sleep apnea is denied. Service connection for sexual dysfunction including erectile dysfunction is denied. ____________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs