Citation Nr: 1806175 Decision Date: 01/31/18 Archive Date: 02/07/18 DOCKET NO. 09-33 154 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a right knee disorder. 2. Entitlement to service connection for a cervical spine disorder. 3. Entitlement to service connection for a urinary/bladder disorder, to include benign prostatic hypertrophy (BPH), claimed as urinary incontinence, and to include as secondary to the service-connected lumbar spine disorder or claimed cervical spine disorder. 4. Entitlement to service connection for erectile dysfunction, to include as secondary to the service-connected lumbar spine disorder or claimed cervical spine disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD L. Crohe, Counsel INTRODUCTION The Veteran had active duty service from September 1984 to July 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), in St. Petersburg, Florida. The Veteran and his spouse testified before the undersigned Veterans Law Judge in December 2015; a transcript of that hearing is associated with the claims file. This matter was remanded by the Board in March 2016 and May 2017 and is now again before the Board for adjudication. FINDINGS OF FACT 1. A right knee disorder did not manifest in service or to a compensable degree within one year of service and is unrelated to service. 2. A cervical spine disorder did not manifest in service or to a compensable degree within one year of service and is unrelated to service. 3. Erectile dysfunction and/or chronic urinary/BPH disorder, was not manifested during service, is not shown to be related to active service, and is not shown to be causally or etiologically related to service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee disorder have not been met 38 U.S.C. §§ 1101, 1110, 1112, 1116, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 2. The criteria for service connection for a cervical spine disorder have not been met 38 U.S.C. §§ 1101, 1110, 1112, 1116, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 3. The criteria for service connection for urinary/bladder disorder to include BPH have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107(b) (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 4. The criteria for service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107(b) (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Legal Criteria for Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or from aggravation of a preexisting injury suffered or disease contracted in line of duty. See 38 U.S.C. § 113; 38 C.F.R. § 3.303. In order to establish service connection on a direct basis, there must be competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). See also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The determination as to whether elements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303 (d). Certain chronic diseases, including arthritis, shall be presumed to have been incurred in service if manifested to a compensable degree within a prescribed period post service (1 year for hypertension) even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). The United States Court of Appeals for the Federal Circuit has clarified that the provisions of 38 C.F.R. § 3.303 (b) pertaining to the award of service connection on the basis of continuity of symptomatology apply to chronic diseases as defined in 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102, Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). A Right Knee Disorder The Veteran contends his right knee disorder is related to service. During his December 2015 hearing, the Veteran reported that he had continued pain and swelling in his right knee since his injury from service. Although he did not seek formal treatment for those symptoms, he self-medicated with medications, ice, and rest. Service treatment records show that in June 1985, the Veteran had complaints of right flank and hip pain after being struck by a pick-up truck as a pedestrian on a sidewalk. He was diagnosed with contusion to right hip and back. An October 1985 bone scan was negative for any significant findings in the right knee. A May 1986 emergency room (ER) evaluation for a right knee injury showed that the Veteran slid into a base and had a right patella deviation to the medial aspect of the right knee with complaints of pain and swelling. On examination, there were abrasions and the patella was tender in place. X-rays of the knee and the patella were negative for fracture. He was seen twice for follow-up treatment and returned to the ER in May 1986 with right knee effusion without deformity and stability with decreased range of motion in flexion. He subsequently was seen in May 1986 due to his right knee giving way and he was diagnosed with medical collateral ligament (MCL) strain. He was seen again for resolving MCL strain. In September 1986, the Veteran had complaints of pain in his right leg for one day. A history of a pulled ligament in his right knee was noted; there was no sign of a current injury on examination. He was assessed with knee pain. A June 1987 separation report of medical history was silent for any k nee conditions, symptoms, or significant injuries. The Veteran indicated that he did not currently have and never had "Trick or locked knee" and "Arthritis, Rheumatism, or Bursitis". Although the Veteran responded "YES" when asked about any "bone, joint or other deformity", a physician elaborated that the Veteran had "Bunions". The June 1987 separation VA clinical evaluation reported the lower extremities as normal. The Veteran is competent to report symptoms that he experienced, a continuity of such symptoms and when his symptoms were first identified. Post-service, on July 1987 VA examination, there were no complaints or indications of a right knee disability, including on review of the musculoskeletal system. An October 1987 VA orthopedic examination included a physical examination of the lower extremities, which showed full range of motion of the knees, normal muscle strength, no muscle atrophy, normal touch and reflexes, and no evidence of tenderness, heat, swelling, erythema, or effusion. VA treatment records dated in April 1996 noted the Veteran's reports of dislocating his right knee in 1985-1986 with complaints of increased pain and swelling. He was diagnosed with degenerative joint disease of the knees. On June 1996 VA examination for the feet, the Veteran reported complaints in his knees with squatting. In October 2005, the Veteran was seen for right knee soreness for 1 year NAR. No previous injury was reported and the Veteran explained that he stands and walks a lot at work. X-rays were normal with no degenerative changes or effusion. He was diagnosed with right knee arthralgia. In a December 2010 report, Dr. S.C. Allen noted the Veteran's reports of having a series of accidents in the military in 1985. He had a sliding injury to his right knee playing softball. He was told that his patella had separated and he required the medic to reduce the patella. He was treated with a brace. He was then doing a fireman's lift and carry for PT at work in December 1984 when he slipped and fell injuring his lower back. He was treated with pain medication and altered activity for a few months, but recovered with residual back pain. Then in the same year (June 2, 1985), he was a pedestrian on the sidewalk when he was struck by a truck and thorn into the road. He was paralyzed and numb on the right side of his body (ER note indicates N/V intact right hip and flank pain). He subsequently was released to full duty, but complained of low back pain, occasionally numbness of the entire right lower extremity (45times a year lasting for 10 to15 minutes). The Veteran reported that his right knee will ache, swell, and at times give out and that this has been a problem since the 1980's. The physician diagnosed the Veteran with right knee patella chondromalacia with mild instability. Dr. S.C. Allen reported that the simple history of a healthy 19 year old suffering injuries and complaining of right knee pain since the injuries would suggest that the knee injuries in about 1985 were the cause of the conditions. Dr. S.C. Allen noted that the Veteran continued to intermittently complain of pain and received treatment of the right knee since 1985. In an addendum opinion (associated with the record in June 2012), Dr. S.C. Allen determined that there was a probable association between the injury in 1985 and the present complaint. The physician clarified that "probable" meant that there was a 51 percent (or greater) chance that the military injury led to the present complaint of knee pain. He added that there was no way to prove or disprove his statement. He further explained that the Veteran had an injury and has suffered with pain and deterioration from the knee since that time. Prior to the injury, he had no complaints and subsequent to the fall, he has had constant complaints. The examiner found that the three injuries led to constant complaint of pain and hastened deterioration of the right knee. The Board notes that in December 2010, Dr. S.C. Allen reported that the right knee pain has not had an x-ray evaluation for many years and routine plain x-rays of the right knee were indicated and should be obtained before a determination could be given; however, it does not appear that Dr. S.C. Allen obtained or reviewed any additional x-ray reports as well as additional treatment records and evaluations before providing his addendum opinion in June 2012. Additionally, Dr. S.C. Allen appeared to base his opinion on the Veteran's subjective reports of having pain in the right knee since the 1980's. However, the Board finds that the Veteran's reports of continuous right knee pain and swelling since service is not credible as will be discussed in further detail below. Therefore, the opinions provided by Dr. S.C. Allen lack probative value. The Veteran underwent a VA examination of his right knee in October 2011, and the examiner opined that his right knee disorder was not related to his noted injury in military service while playing softball. The examiner noted, as part of the rationale for that opinion, that the Veteran did not have any right knee complaints from 1997 through 2000. The examiner ignored an April 1996 treatment note indicating right knee pain and swelling. The examiner also ignored the 2010 private physician's opinion. Moreover, after the report, the Veteran testified in his December 2015 hearing that he had continued pain and swelling since his injury from service, although he did not seek formal treatment for those symptoms; rather he self-medicated the symptoms with medications, ice and rest. In June 2016, the Board found that the October 2011 VA examiner's opinion was inadequate as he failed to address the April 1996 evidence of right knee issues. In June 2016, the Board remanded the claim in order to obtain another VA examination and medical opinion. Following the Board's remand, the Veteran was afforded a VA examination in July 2016. The examiner noted a diagnosis of arthritis in the right knee in 2012. The examiner noted a December 2011 MRI revealing a meniscal tear and chondromalacia. A February 2012 arthroscopic surgery note, however, revealed an intact meniscus. Post surgery notes indicate knee pain due to arthritis. The examiner reviewed the medical evidence and concluded that it is less likely than not that the current right knee condition is related to his noted right knee injury while playing softball in service. The basis for this opinion was that the knee condition had resolved by discharge and medical records "are silent for any R knee condition until 2005, and 2010...The amount of time between a 1986 knee injury and a 2011 diagnosis does not support a nexus between the two." The examiner made no mention of the 1996 treatment record, or the 2010 private report. The RO then ordered an addendum opinion to consider the April 1996 VA treatment record, the October 2011 VA examination and opinion, the private physician's 2010 examination and opinion and the May 2012 addendum opinion from that private physician. In the September 2016 addendum, the same examiner simply again noted that the Veteran reported no symptoms at the time of his separation from service, and then went on to note that the April 1996 physician noted knee pain and osteoarthritis, but that the osteoarthritis diagnosis was not based upon diagnostic testing. The VA examiner merely stated that it was an inaccurate diagnosis, but did not discuss the relevance of the reported knee pain in 1996. Moreover, the examiner again failed to consider the Veteran's statements indicating right knee pain since the 1980s and the Board remanded the claim again for a new opinion in May 2017. The Veteran was afforded a VA knee and lower leg conditions DBQ in July 2017, in which the examiner noted the Veteran's history, including his contentions that his symptoms have persisted since his active duty injury. The examiner summarized the Veteran's relevant medical history and added her own interpretation of the records, for example, the examiner noted that the October 1985 bone scan showed that there was no increased uptake in the knees, which was evidence against knee trauma residuals from the 1985 motor vehicle accident. Regarding the May 1986 ER evaluation for the right knee, the ER clinician noted that the patella was in place and the knee could be fully extended and flexed to 90 degrees. His ligaments were intact and x-rays of the knee and patella were negative for fracture. The examiner found that this record reflected an acute and transient deviation of the patella. Also, on the June 1987 separation report of medical history, the Veteran did not list his acute and transient right knee softball injury on his otherwise detailed history form and the record was silent for a knee condition/symptoms/significant injury. The examiner considered that the Veteran filed a claim for lower back pain in July 1987, but did not include any knee condition. The examiner believed that it was highly unusual that the Veteran would not include a claim for a right knee condition in which he experienced swelling and pain "any time I [he] would run or stand." Regarding an April 1996 VA treatment record noting the Veteran's reports of right knee dislocation with an assessment of degenerative joint disease of the knees, the examiner reported that no radiographic studies were reported or ordered. Additionally, the examiner added that documented absence of laxity went against a chronic patellar dislocation. The examiner stated that in the absence of a chronic laxity, it was highly unlikely that a remote acute and transient patellar dislocation (with normal post reduction radiographs) would be the cause for subsequent symptoms/disorders or disabilities. The examiner found that any examination abnormalities at this time (10 years after the active duty injury) were mostly likely related to the stresses placed upon the knee (to include aging) during the many years since separation. The Veteran described having routinely performed physical strenuous occupational and recreational activities for the initial 20 years post active duty. The examiner reviewed additional treatment records, in which the examiner noted that an August 1999 record included a full history and physical and there were no reports of right knee symptoms, conditions/injuries, or examination abnormalities. Additionally, a December 1999 record did not include any reports of right knee symptoms. An orthopedic consult in 2003 documented hip/pelvis complaints with an absence of any documented knee symptoms, conditions/injuries or examination abnormalities, which the examiner found to be highly significant. The examiner felt that if knee issues had been present at that time, it would have most likely been documented within the orthopedic consultation report. The examiner added that the knees had been routinely assessed (for history of significant injury, conditions, symptoms, or physical examination abnormalities) as part of an evaluation of hip/pelvis symptoms. The examiner explained that flexion and extension of the knee was performed during the testing of the hip range or motion. The 2003 orthopedic consult documented the presents of "Full" range of motion of the hips without pain. Therefore, the examiner determined that this evidence went against the presence of a chronic right knee condition at the time. Additionally, the November 2003 orthopedic consult reflected an evaluation for the Veteran's left knee twisting injury. The examiner found that the absence of documented right knee symptoms, conditions/injuries, or examination abnormalities was highly significant because if a right knee issue had been present, it would have most likely been documented. The examiner explained that the opposite knee is routinely assessed as part of an evaluation of a knee injury. In May 2005, the Veteran was seen for complaints of left foot pain as well as off and on neck and back pain for years. The examiner noted that the Veteran reported that he was "on feet all the time", but did not report any knee symptoms or examination abnormalities. The examiner added that the October 2005 orthopedic consult noted complaints of right knee "Global soreness for 1 year for NAR [no apparent reason]" with "no abnormalities on exam or x-ray". At that time, the Veteran reported that he "Stands and walks a lot at work" and "No swelling", which the examiner found went against the Veteran's recollection that ever since the active duty injury "when I stood or run it would swell". No patellar laxity was identified. The examiner also found that it was notable that the orthopedic specialist did not list the 1985 patellar dislocation as a potential etiology of the current symptoms. The examiner opined that it was highly unlikely that a patellar dislocation in an athletic young man would be the cause of knee soreness 18 years later. The examiner reviewed a January 2007 orthopedic consult for back and bilateral hip pain and noted that it was negative for any report of right knee symptoms or abnormalities. The examiner reported that an orthopedist documented "Positive Waddell's", which the examiner noted was an indication of subjective-objective incongruity. The examiner found that subjective-objective incongruity was documented in multiple service treatment records/treatment records and disability entries. The examiner explained that the pattern of incongruity lessoned the credibility of the Veteran's self-reported symptomatology. Regarding the December 2010 independent medical evaluation, the examiner found that Dr. S.C. Allen's findings (23 years post active duty) supported the subsequently documented chondromalacia patella; however, the absence of laxity/subluxation went against a longstanding residual of the acute and transient 1985 patella deviation/dislocation. Additionally the Veteran's VA orthopedic consultation reports dated in October 2003, November 2003, and October 2005, were not among the records listed as reviewed by Dr. S.C. Allen. Also, Dr. S.C. Allen reported that he did not have any x-rays to review and x-rays subsequently obtained in December 2010 were normal, per radiologist. The December 2010 normal findings on the right knee x-rays performed greater than twenty years after separation noted complaints of pain for over 10 years. The examiner reviewed February 2012 x-rays, which he reported as documenting the earliest radiographic identification of degenerative joint disease. There was 'no evidence of fracture or subluxation", which the examiner determined went against the notion of progression or persistence of remote patellar dislocation and described separation. Overall, the examiner opined that it was less likely as not (less than 50/50 probability) that any right knee disorder present had its onset during the Veteran's active service, or is otherwise the result of any in-service disease or injury. The examiner based her opinion upon medical literature review, clinical experience, medical record review, and evaluation of the Veteran. The examiner noted the Veteran reports and service treatment records documenting a February 1986 right knee injury with described acute and transient deviation of the right patella. Service treatment records documented that the patella had reverted to its normal position prior to the ER assessment. A right knee/patella assessment one week post-injury, documented and absence of deformity and the presence of stability, which the examiner stated was evidence against persistent patellar laxity/instability. Although effusion and decrease in flexion were noted, the examiner reported that this would be expected for one week after the described acute injury. The Veteran reported that he returned to full duty after period of physical therapy and brace usage. The examiner found that subsequent service treatment entries went against development of a chronic right knee disability/disorder. On his separation report of medical history form, the Veteran responded "NO" when asked about currently having or ever having "'Trick' or locked knee" and for "Arthritis, Rheumatism, or Bursitis". The examiner explained the acute and transient right knee softball injury, or the history of any knee symptoms or conditions, was not written on this otherwise detailed history form. The examiner noted that the Veteran described having performed physically strenuous occupational and recreational activities until he left his corrections officer position in 2006. The examiner added that multiple treatment records documented right knee complaints in 1996, 2005, 2010 (and forward), while multiple interval assessments were silent for right knee symptoms/conditions/exam abnormalities. The examiner found there was subjective-objective incongruity documented within multiple assessments-to include service treatment records, multiple treatment records, and disability evaluation entries. The examiner reviewed and considered the relevant medical and lay evidence, to include the Veteran's hearing testimony and the statements provided by his spouse; however, the pattern of incongruity and the inconsistencies noted within the history, lessens the credibility of Veteran's self-reported symptomatology and the lay evidence. The Veteran denied having had a recurrence of patellar dislocation. Multiple post injury assessments--to include the current examination--documented stability of the knee and patella. In this clinical setting, the examiner opined that the Veteran's post-injury symptoms and conditions were less likely as not related to the active duty injury. The examiner found that it was most likely that the right knee abnormalities/disabilities/disorders identified 10 to 30 years after separation were the result of stress placed upon the knee after Veteran's 34 months of active duty. In adjudicating a claim, the Board is charged with the duty to assess the credibility and weight given to evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The probative value of a medical opinion primarily comes from its reasoning; threshold considerations are whether a person opining is suitably qualified and sufficiently informed. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the Board accepts the July 2017 VA examiner's opinion that it was at least as likely as not that any right knee disorder present had its onset during the Veteran's active service, or is otherwise the result of any in-service disease or injury as highly probative medical evidence on this point. The Board notes that the examiner rendered her opinion after thoroughly reviewing the claims file and relevant medical records. The examiner noted the Veteran's pertinent history and provided a reasoned analysis of the case. See Hernandez-Toyens, 11 Vet. App. at 383; Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994) (the probative value of a physician's opinion depends in part on the reasoning employed by the physician and whether or not (or the extent to which) he reviewed prior clinical records and other evidence). The Board has also considered the lay statements of record, to include the Veteran's assertion that he suffered a right knee injury from sliding into base, slipping and falling during physical therapy, and getting hit by a pick-up truck during service. Here, the Veteran is competent to report his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). To the extent the Veteran has stated that his knee pain and swelling has existed since his service, these statements are inconsistent with the other lay and medical evidence of record. In determining the weight to be assigned to evidence, credibility can be affected by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996). The Board finds that the probative value of the general lay assertions is outweighed by the clinical evidence of record. Physical examination upon separation from service revealed normal lower extremities and the Veteran specifically denied having or ever having knee problems. Additionally, post service records included a July 1987 VA examination and an October 1987 VA orthopedic examination that did not reveal any right knee abnormalities on review of the musculoskeletal system and/or the lower extremities. The first complaint of right knee pain was in April 1996, which was nine years after his discharge from service. Since then multiple treatment records, included a review of the extremities and were negative for any complaints, treatment, or diagnoses of a right knee condition until October 2005. During an October 2005 orthopedic consult the Veteran indicated that he had right knee pain for one year and denied swelling, which went against his statements suggesting that he had pain and swelling since service. As the Veteran's statement concerning persistent knee pain and swelling since service is substantially inconsistent with both his previous statements of record and the medical evidence at the time of his separation and following his separation, the Board finds his statements to be not credible and therefore entitled to no probative weight. Id. Additionally, as Dr. S.C. Allen relied on the Veteran's reports of continuity of knee symptoms when formulating his opinions, his opinions also lack probative value. The July 2017 VA examiner's opinion was far more detailed and reasoned and supported by the medical evidence of record. Additionally, the VA examiner specifically addressed inconsistency of the Veteran's reports of continuity. Thus the July 2017 VA opinion warrants a greater probative value. In sum, there is no reliable probative evidence linking the Veteran's right knee disorder to service. The contemporaneous records establish that there were no objective manifestations of a right disorder in service, the right knee was physically normal upon separation, the Veteran denied any subjective complaints regarding a right knee problem, there were no manifestations of a right knee disorder within one year of separation, and a right knee disorder was first manifest many years after separation. The Board finds the contemporaneous records and the July 2017 VA opinion to be far more probative and credible than the Veteran's reported onset and continuity and treatment as well as the opinions provided by Dr. S.C. Allen. Here, a right knee disorder was not "noted" during service within the meaning of section 3.303(b). While the Board notes the Veteran's history of a right knee injury during service, the Board finds that the service treatment records do not show a combination of right knee manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Furthermore, the probative evidence does not establish that a right knee disorder was manifest to a compensable degree with one year of separation. 38 C.F.R. §§ 3.307; 3.309. Rather, the examinations during the pertinent time frame were normal. In essence, the evidence establishes that the right knee was normal upon separation from service and the onset of a right knee disorder occurred many years after service. The Board finds that the contemporaneous in-service and post-service treatment records are entitled to greater probative weight and credibility than the lay statements of the Veteran and the opinions provided by Dr. S.C. Allen. The more probative evidence establishes that he did not have a chronic right knee disorder during service or within one year of separation. Furthermore, the probative evidence establishes that the remote onset of a right knee disorder is unrelated to service. The Board again acknowledges that the Veteran is competent, even as a layperson, to attest to factual matters of which he has first-hand knowledge, e.g., an injury during his active military service. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Buchanan, supra; Jandreau, supra. However, as a layperson, it is not shown that the Veteran possesses the medical expertise to provide a medical opinion linking his currently diagnosed right knee disorder to his in-service injuries. The only probative medical opinion of record addressing the claimed relationship is negative. The Board finds that the preponderance of the evidence is against the claim and the claim must be denied. B. A Cervical Spine Disorder The Veteran contends his cervical spine was injured during the same incidents that caused his now service-connected lumbar spine disability. At his December 2015 hearing, the Veteran reported that he hurt his neck at a time in service when he was buffering a floor and slipped on wax and fell. See hearing transcript at page 4. He also reported hurting his neck during a firearms carry and that he has experienced tightness in his neck ever since that incident. Id. at page 7. And, he reported experiencing pain in his neck at the time he was hit by a truck. Id. at page 8. The Veteran's wife also testified that she and the Veteran had been married for 26 years and she recalled not being able to do things or needing to make adjustments when they were a young couple in part due to his neck problems. Id. at pages 12-13. This testimony suggests ongoing symptoms since the 1980s. Service treatment records are negative for any complaints, treatment, or diagnoses relating to any neck problem. Service treatment records do show that in December 1984, the Veteran was treated for low back pain associated with carrying an individual on his back. The clinical impression was low back strain. In June 1985, he was struck by an automobile and had contusions to the right hip and the lower back; x-rays of the hip and spine were negative, but there was some limitation of motion due to back pain and the clinical impression was right low back pain (LBP) secondary to contusions. A repeat x-ray of the spine in July 198 5 was again negative. A treatment note in August 1985 noted that the Veteran complained of chronic back pain with radiation since the automobile accident in June; the clinical impression was resolving mechanical LBP with normal back examination. Service treatment records reflect treatment for the Veteran's low back in November 1985, December 1985, and August 1986. An October 1986 treatment record noted complaints of back pain associated with a fall while waxing the floor. A clinical examination was normal and the impression was LBP. A June 1987 separation report of medical history was silent for any cervical spine conditions, symptoms, or significant injuries. The Veteran indicated that he did not currently have and never had "Arthritis, Rheumatism, or Bursitis". Although the Veteran responded "YES" when asked about any "bone, joint or other deformity"; "Painful or 'trick' shoulder or elbow" and "Recurrent back pain", a physician elaborated that the Veteran had "Bunions" as well as left shoulder and lower back pain. The June 1987 separation clinical evaluation reported the "spine other musculoskeletal" as normal. The Veteran is competent to report symptoms that he experienced, a continuity of such symptoms and when his symptoms were first identified. Post service records include a July 1987 VA examination that documented a normal evaluation of the head, neck, and face. A neck disorder was not identified on review of the musculoskeletal system. An October 1987 VA orthopedic examination noted the Veteran's June 1985 motor vehicle accident. The Veteran reported that he injured his back and there were cuts and bruises on his elbows and head. An evaluation of the head, neck, and face was normal. No neck abnormalities were identified on review of the musculoskeletal system. An August 1999 VA treatment record noted that the Veteran had complaints of back pain since his in-service accident and underwent a physical examination. The record was negative for any complaints, treatment, or diagnoses relating to any cervical spine problems. The Veteran presented to Dr. G. Pierce Jones in December 1999 complaining of LBP since an injury in service in 1984 while doing a fireman's lift; he also described having been hit by a truck while in service. The treatment records were negative for any complaints, treatment, or diagnoses related to any neck problems. A September 2007 letter from Dr. R.L. Verrier, a private chiropractor, stated that Dr. Verrier was currently treating the Veteran for injuries sustained in an MVA in 1985. Based upon a review of the Veteran's history and his recent statements, Dr. R. L. Verrier stated in an opinion "within a reasonable degree of certainty that his injuries are possibly related to the 1985 accident" (quotation marks in the original). The Board finds such opinion to be of minimal to no probative value because Dr. Verrier failed to provide any rationale for his conclusion and identify the current conditions for which he was treating the Veteran. In May 2005, the Veteran was seen for complaints of left foot pain as well as off and on neck and back pain for years. X-rays dated in January 2009 revealed minimal disc space narrowing at C2-3 and minimal bony spondylosis at C5-6 and C6-7 with minimal neural foramina narrowing at C4-5 on the right. A March 2009 MRI revealed multilevel neural foraminal narrowing. A May 2009 pain clinic consult noted that the Veteran's reports of having neck pain for 10 years. At the same time, the Veteran reported that he has had lower back pain since his motor vehicle accident in 1985. A February 2010 MRI included a diagnosis of multilevel mild degenerative disc disease with disc bulges and C4-5 foraminal stenosis. Current VA treatment records include a past medical history of "Other syndromes affecting cervical region" and "Cervical spondylosis without myelopathy". The Veteran presented to private chiropractor Dr. J. M. Casanova in June 2009 with complaints of LBP and neck pain. He reported that his LBP began in 1987 and his neck pain began eight months ago. He indicated that his LBP began when he was hit by a vehicle and that he was not sure how his neck pain began. In August 2009, based on the history and examination findings, Dr. J. M. Casanova's prognosis was that the Veteran would likely have continued complaints of LBP as he had in the past due to the injury sustained in 1985. Dr. J. M. Casanova's did not mention the Veteran's cervical spine disorder in conjunction with the 1985 injury. In December 2010, Dr. S. C. Allen submitted a narrative report after evaluation of the Veteran. The history section of this report included notation of in-service incidents involving the Veteran's lumbar spine, but there was no indication that the Veteran reported a neck injury occurring in service. Further, the physician noted that the Veteran was on light or altered duty for seven to eight months of his active service. The Board is unaware of the basis for this statement. Service treatment records reflect that at the time of his motor vehicle accident in Jun 1985, he was placed on modified duty. He subsequently underwent physical therapy and was placed on a profile. An August 1985 treatment record documented that there was no need for a profile and that the Veteran was to return to full duty. The physician confirmed the current cervical spine symptoms experienced by the Veteran, provided a diagnosis of cervical spondylosis, and later stated that the Veteran suffered three military related accidents resulting in neck pain. However, there is no explanation as to this statement, considering earlier in the report, the physician reported the Veteran's history and included no indication of symptoms in the neck in service. The physician went on to provide a positive nexus opinion, but the rationale is inconsistent with the earlier report of the Veteran's history. Thus, this report lacks probative value with regard to the cervical spine claim. The Veteran's spouse submitted a letter dated in March 2011 in which she described the Veteran's current impairment of function due to generalized pain. In May 2012, Dr. S. C. Allen submitted an addendum to his December 2010 examination report cited above. Dr. S.C. Allen stated that his assertion of a "probable association" was intended to convey that it is at least 51 percent likely that the Veteran's military injuries led to his present complaints. Dr. S. C. Allen further stated that there is no way to either prove or disprove this opinion. The Veteran was injured in service and has subsequently suffered with pain and physical deterioration. Prior to the injury the Veteran had no complaints, and since the injury he has had constant complaints. Thus, the association goes to demonstrate a direct cause-and-effect relationship; the three military injuries have led to constant complaint of pain and hastened deterioration of the neck. The Board finds that Dr. S.C. Allen did not explain how he found that the Veteran's current neck disability was related to an in-service injury, given that when he reported the Veteran's history, there was no indication of neck symptoms or a neck injury in service. Additionally, Dr. S.C. Allen appeared to base his opinion on the Veteran's subjective reports of having pain in the right knee since the 1980's. However, the Board finds that the Veteran's reports of continuous neck pain since service is not credible as will be discussed in further detail below. Therefore, the opinions provided by Dr. S.C. Allen lack probative value. In March 2016, the Board ordered a VA examination related to this claim. The July 2016 examiner confirmed the existence of cervical spine degenerative joint disease based upon the findings in a March 2009 MRI of the cervical spine. The examiner opined that the cervical spine disability is less likely as not to have begun in or otherwise be related to the Veteran's military service. The rationale was the absence of notation of a neck condition on the June 1987 separation examination report, and absence of notation of a neck condition in the records at the time he was struck by a truck in service. The examiner went on to state that the first record of a diagnosed neck condition is in 2009 and the length of time between his exit from service and the diagnosis of a neck condition is far too much time to support a nexus between the two. In a September 2016 addendum, the examiner restated the prior opinion and reasoning. As the examiner made no mention in the rationale of the competent lay reports of neck pain at the time of the in-service incidents and since, in May 2017, the Board found that the opinion lacked probative value and remanded the claim for a new opinion. See Dalton, 21 Vet. App. 23. The Veteran was afforded a July 2017 VA neck (cervical conditions) DBQ examination, the examiner recorded the Veteran's reported history of developing neck pain in June 1985 when he was hit by a truck and having chronic cervical pain since that time. The examiner noted that the ER note at that time did not document neck problem/complaints. The examiner acknowledged the Veteran's reports that his pain worsened gradually over the years. The examiner considered that the duties of the Veteran in the military required some lifting, a lot of carrying heavy equipment on the back, some jumping, a lot of marching, and a lot of running. The examiner summarized relevant records in the Veteran's electronic file and noted that service treatment records revealed that the Veteran was involved in a motor vehicle accident in June 1985; however, his chief complaints was pain in the right hip and there was no mention of a neck problem. The examiner noted that a subsequent emergency care record showed that the Veteran was seen again with complaints of right flank and hip pain with no mention of a neck problem. Also, the October 1985 bone scan (while in service) did not mention any abnormality of the cervical spine. On his June 1987 report of medical history, the Veteran did not mention any neck problems. The examiner also summarized VA treatment records as well as the December 2010 report from Dr. S.C. Allen. The examiner opined that the diagnosis of cervical spondylosis was less likely as not (less than 50 probability) incurred in service or caused by a service event. The examiner stated that his opinion was provided based on his evaluation of the Veteran and based on reviewing the medical records of the Veteran. The examiner stated that the objective evidence finds absence of the diagnosis of cervical spondylosis being incurred in service or caused by a service event. The probative value of a medical opinion primarily comes from its reasoning; threshold considerations are whether a person opining is suitably qualified and sufficiently informed. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the Board accepts the July 2017 VA examiner's opinion that the diagnosis of cervical spondylosis was less likely as not incurred in service or caused by a service event. The Board notes that the examiner rendered his opinion after thoroughly reviewing the claims file and relevant medical records. The examiner noted the Veteran's pertinent history and provided a reasoned analysis of the case. See Hernandez-Toyens, 11 Vet. App. at 383; Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). The Board has also considered the lay statements of record, to include the Veteran's assertion that he suffered a right knee injury from sliding into base, slipping and falling during physical therapy, and getting hit by a pick-up truck during service. Here, the Veteran is competent to report his observations. See Jandreau, 492 F.3d 1372, 1377 (Fed. Cir. 2007). To the extent the Veteran has stated that his neck pain has existed since his service, these statements are inconsistent with the other lay and medical evidence of record. The Board finds that the probative value of the general lay assertions is outweighed by the clinical evidence of record. Treatment records throughout the Veteran's service are negative for any complaints, treatment, or diagnoses related to any neck problems, including treatment surrounding when the Veteran was involved in a motor vehicle accident as well as any other time he sought treatment for his low back. Physical examination from service revealed a normal musculoskeletal system and the Veteran. At the same time, he did not report any neck problems when asked to report his medical history. Additionally, post service records included a July 1987 VA examination and an October 1987 VA orthopedic examination that did not reveal any neck abnormalities on review of the musculoskeletal system and/or the head, neck and face. The first complaint of right knee pain was in May 2005, which was approximately 18 years after his discharge from service. During a May 2009 pain clinic consult, the Veteran indicated that he had neck pain for 10 years, while reporting that he had low back pain since his accident in 1985. While seeking treatment from Dr. Casanova in June 2009, the Veteran reported that his neck pain began eight months ago and that he was not sure what caused the pain however, he specifically reported that his low back pain began in 1987 from when he was hit by a vehicle. The Veteran's statements to his providers regarding his when and how his neck pain began went against his statements made in conjunction with his current claim suggesting that he had neck pain since service. As the Veteran's statement concerning persistent neck pain since service is substantially inconsistent with both his previous statements of record and the medical evidence at the time of his separation and following his separation, the Board finds his statements to be not credible and therefore entitled to no probative weight. Id. Additionally, as Dr. S.C. Allen relied on the Veteran's reports of neck symptoms in service as well as continuity of neck symptoms when formulating his opinions, his opinions also lack probative value. The July 2017 VA examiner's opinion was far more detailed and reasoned and supported by the medical evidence of record; thus warranting a greater probative value. In sum, there is no reliable probative evidence linking the Veteran's neck disorder to service. The contemporaneous records establish that there were no objective manifestations of a neck disorder in service, the neck was physically normal upon separation, the Veteran denied any subjective complaints regarding a neck problem, there were no manifestations of a neck disorder within one year of separation, and a neck disorder was first manifest many years after separation. The Board finds the contemporaneous records and the July 2017 VA opinion to be more probative and credible than the Veteran's reported onset and continuity and treatment as well as the opinions provided by Dr. S.C. Allen. The probative evidence establishes that the remote onset of a neck disorder is unrelated to service. The Veteran, as a layperson, it is not shown to possess the medical expertise to provide a medical opinion linking his currently diagnosed neck disorder to his in-service injuries. See Washington, 19 Vet. App. 362, 368 (2005); Buchanan, supra; Jandreau, supra. The only probative medical opinion of record addressing the claimed relationship is negative. C. Erectile Dysfunction and Chronic Urinary/BPH Disorder The Veteran contends that both his urinary/BPH problems and his erectile dysfunction are associated with his lumbar spine disability. See hearing transcript at page 14. Service treatment records include a June 1985 screening note of medical care regarding follow-up care for hip and back pain that noted that the Veteran had increased urination since his injury. He denied any discharge. Subsequently, in June 1985, he was provided with an assessment of contusion of right kidney with urinary tract infection. In September 1986, he had complaints of discharge for one day and burning with urination. In October 1986, he denied having painful urination. In November 1986, he presented with progressive back pain for the past three weeks with increased frequency of urination, dysuria and nocturia. A history was noted of being struck in the lower back by a truck a year ago. He was diagnosed with mechanical low back pain and clinical prostatitis. A November 1986 screening note of acute medical care noted low back pain for weeks, and painful frequent urination that was not associated with urethral discharge. In March 1987, he had complaints of itching in penis and dysuria. A March 1987 screening note of acute medical care noted a urinary tract infection associated with urethral discharge. Another May 1987 treatment record noted that the Veteran had treatment for a sexually transmitted disease in February, but had current complaints of urethral discharge for one day. A June 1987 separation report of medical history was silent for any urinary/bladder or erectile dysfunction conditions, symptoms, or significant injuries. The Veteran indicated that he did not currently have and never had "Frequent or painful urination", "kidney stone or blood in urine", or "Sugar or albumin in urine". Although he responded "YES" when asked about any "VD-Syphilis, gonorrhea, etc.", a physician elaborated that the Veteran had "Gonorrhea" in 1987 that was treated with medicine. The June 1987 separation clinical evaluation reported the G-U system as normal. Treatment records from Southeastern Urology Center in dated January 1997 included a diagnosis of erectile dysfunction. An April 2003 record noted left testis pain of unknown origin. In July 2003, he was diagnosed with epididymitis. In October 2003, he underwent a vasectomy. A February 2005 treatment record documented resolving left testicular pain on antibiotic therapy (had been recurrent for the last 2-3 years) and a history of erectile dysfunction. In October 2008, the provider noted that the Veteran continued to have post-void dribbling that had been longstanding. The Veteran denied frequency, dysuria, nocturia, and urgency. He was diagnosed with a history of BPH and erectile dysfunction. A December 2010 record from Dr. S.C. Allen noted symptoms of urinary frequency and sexual dysfunction. On July 2011 VA examination, the examiner noted in service treatment for nonspecific urethritis, frequent urination, and prostatitis. During the examination, the Veteran reported that he has been experiencing nocturia and leaking urine since 1995. The examiner confirmed the existence of minimal BPH manifested by post-void dribbling. The existence of erectile dysfunction was also confirmed in this report. The examiner opined that the Veteran's current minimal BPH was not caused by his condition diagnosed during active duty. The examiner reasoned that the Veteran has no symptoms of incontinence, but rather post-void dibbling, which may be related to his minimal BPH. The examiner further stated that the Veteran's prostatitis and urethritis were treated with antibiotics during service and were not causally related to BPH. The examiner stated that prostatitis/ urethritis were temporary and reversible conditions with antibiotic s and treatment. December 2015 records from Southeastern Urological Center noted the Veteran's history of long-standing post-void dribbling. The Veteran denied any frequency, urgency, and nocturia; however, the examiner later noted that the Veteran did have complaints of urinary frequency. This physician also noted the Veteran's belief that "some of that dysfunction may be secondary to a herniated disc in the low back". The Veteran was diagnosed with erectile dysfunction and a history of BPH. He was prescribed Levitra. As the Veteran was granted service connection for a low back disability during the course of the appeal, in March 2016, the Board remanded the urinary/BPH and erectile dysfunction claims for VA examination and opinion. On July 2016 VA examination, the Veteran reported a history of urinary frequency for about 16-17 years. He reported that he saw an urologist about 10 years ago for erectile dysfunction. He said he was told that his prostate was "a little bit" enlarged. The VA examiner found that there was no current evidence of an enlarged prostate and no evidence of urinary tract pathology. The examiner added that there was no evidence of chronic urinary problems in service or within a year of separation from service. The examiner also stated that erectile dysfunction was not incurred in, caused by, or aggravated by service. The examiner reasoned that a review of the medical evidence was against the presence of erectile dysfunction in service or within one year of separation from service. In May 2017, the Board found that the July 2016 VA examiner's opinion was inconsistent with the 2011 VA examiner's findings and the private urologist's report from December 2015 that reflected BPH and urinary issues, also the 2016 examiner made no mention of the prior findings, therefore, in May 2017, the Board remanded the claims for a new examination and opinion. On July 2017 VA male reproductive system conditions DBQ, the Veteran was diagnosed with testosterone deficiency with incomplete erectile dysfunction and BPH with lower urinary tract symptoms. The Veteran reported that his urinary frequency increased over the years. He indicated that it had been approximately seven or eight years since he last had an episode of epididymitis symptoms. The examiner noted that the Veteran's remote symptoms were acute and transient; resolved without residuals. The Veteran reported a small amount of post-void dribbling. He reported that this had been going on for at least eight or nine years. He indicated that he started to notice erectile dysfunction around 1997-1998. The examiner opined that the Veteran's erectile dysfunction was as likely as not attributable to his low testosterone. The examiner opined that the Veteran's erectile dysfunction and/or urinary/BPH disorder present during the pendency of the claim were less likely as not (less than 50/50 probability) related to a disease or injury in service, or due to or aggravated by the Veteran's service connected lumbar spine disability. The examiner based her opinion upon medical literature review, clinical experience, medical record review, and evaluation of the Veteran. The examiner reported that the Veteran described and multiple treatment records substantiated that his symptoms of erectile dysfunction and/or urinary/BPH disorder had its onset years after active duty. The examiner also explained that the 2008 urology specialty evaluation documented BPH as the etiology for the Veteran's lower urinary tract symptoms and low testosterone as the cause for his erectile dysfunction. The examiner opined that BPH and low testosterone were less likely as not etiologically related to a disease or injury in service, or due to or aggravated by the Veteran's service-connected lumbar spine disability. The examiner reasoned that these conditions (BPH and low testosterone) were pathophysiologically unrelated to the Veteran's service connected conditions to include his lumbar spine disability. The examiner added that the Veteran's examination findings included normal perineal/sacral region sensation as well as normal anal wink and cremasteric reflexes. The examiner reported that this evidence went against a spinal condition etiology for claimed erectile dysfunction and urinary symptoms. The examiner commented that the evidence went against a nexus between these claimed conditions and the Veteran's military service. Based upon the evidence of record, the Board finds that erectile dysfunction and/or chronic urinary/BPH disorder were not manifest during active service, are not shown to have developed as a result of an established event, injury, or disease during active service, and are not due to or aggravated by a service connected disability. Further, while there are complaints increased frequency of urination, dysuria, nocturia, and urethral discharge as well as such diagnoses of urinary tract infection, prostatitis, and gonorrhea that does not equate to a finding of a chronic erectile dysfunction and/or chronic urinary/BPH disorder. A June 1987 separation report of medical history was silent for any urinary/bladder or erectile dysfunction conditions, symptoms, or significant injuries. The Veteran indicated that he previously had a venereal disease and a physician elaborated that the Veteran had "Gonorrhea" in 1987 that was treated with medicine. The June 1987 separation clinical evaluation reported the G-U system as normal. Additionally, the July 1987 VA examiner found that the Veteran's in-service prostatitis and urethritis were treated with antibiotics during service and were temporary and reversible conditions with antibiotic s and treatment. Post service, an erectile dysfunction and/or chronic urinary/BPH disorder was not diagnosed until January 1997, approximately ten years after separation from active service. The Board finds that the VA examiner's opinions, provided in July 2011 and July 2017, constitute probative evidence on the medical nexus questions, based as it was on review of the Veteran's documented medical history and assertions and examination. Prejean v. West, 13 Vet. App. 444 (2000); Guerrieri v. Brown, 4 Vet. App. 467 (1993). The July 2011 VA examiner's opinion sets forth that the Veteran's current minimal BPH was not caused by his condition diagnosed during active duty. The examiner reasoned that the Veteran's prostatitis and urethritis were temporary and reversible conditions with antibiotic treatment during service and were not causally related to BPH. Additionally, the July 2017 examiner opined that the Veteran's erectile dysfunction and/or urinary/BPH disorder present during the pendency of the claim were less likely as not related to a disease or injury in service. The examiner reported that the Veteran described and multiple treatment records substantiated that his symptoms of erectile dysfunction and/or urinary/BPH disorder had its onset years after active duty. Further, the VA examiners' opinions are consistent with the other evidence of record. Additionally, the July 2017 VA examiner opined that the Veteran's erectile dysfunction and/or urinary/BPH disorder present during the pendency of the claim were less likely as not due to or aggravated by the Veteran's service connected lumbar spine disability. The examiner reasoned that the conditions were pathophysiologically unrelated to the Veteran's service-connected lumbar spine disability because examination findings showed a normal perineal/sacral region sensation as well as normal anal wink and cremasteric reflexes. Significantly, the Veteran has not presented or identified any contrary medical opinion that supports any of the claims for service connection. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66(1991). The Board finds that the most persuasive evidence of record shows that the current erectile dysfunction and/or urinary/BPH disorder are not related to service or to a service-connected disability, including a lumbar spine disability. In addition, while the Veteran is competent to describe his symptoms, the Board finds that there is no evidence of record to show that he has the specialized medical education, training, or experience necessary to render a competent medical opinion as to the nature and etiology of the claimed erectile dysfunction and/or urinary/BPH disorder. Diagnosing and providing an etiology of erectile dysfunction and/or urinary/BPH disorder is medically complex in nature. Jandreau, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, any opinion by the Veteran regarding etiology of any of these conditions is not competent because he does not have the training to opine on that medical issue. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the Board finds that the preponderance of the evidence is against the claims for service connection for erectile dysfunction and/or urinary/BPH disorder. Therefore, each of those claims are denied. ORDER Entitlement to service connection for a right knee disorder is denied. Entitlement to service connection for a cervical spine disorder is denied. Entitlement to service connection for a urinary/bladder disorder, to include BPH is denied. Entitlement to service connection for erectile dysfunction is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs