Citation Nr: 18140864
Decision Date: 10/09/18	Archive Date: 10/09/18

DOCKET NO. 17-33 847
DATE:	October 9, 2018
REMANDED
Entitlement to a compensable disability rating for cystitis is remanded.
REASONS FOR REMAND
The Veteran served on active duty from July 1974 to November 1974 and from November 1974 to April 1984.
Entitlement to a compensable disability rating for cystitis is remanded.
To ensure that VA has met its duty to assist, remand is necessary.  38 C.F.R. § 3.159(c).  First, the record is incomplete.  The record shows that a May 2017 VA medical opinion addendum was requested and obtained by the originating agency; however, it is not associated with the claims file.  Second, although an addendum was requested, the medical question posed by the originating agency was limited to whether cystitis was proximately due to cystocele and did not ask whether there was aggravation beyond normal progression (thereby linking service-connected cystitis to nonservice-connected cystocele).
Historically, a March 2015 VA examination reflects that the Veteran’s current urinary symptoms (frequency, urgency, and incontinence) are at least as likely as not related to her cystocele and not to her service-connected cystitis.  The examiner added that her cystocele is less as likely as not related to her cystitis.  An April 2017 VA examination noted that, since the 2015 VA examination, the Veteran underwent surgery in October 2015 to correct the cystocele and still had urinary frequency and urgency.  The examiner noted that a March 2017 treatment note indicated weakened pelvic floor strength.  The examiner indicated that the Veteran had a voiding dysfunction and that the weakened pelvic floor was the etiology.  Following the April 2017 VA examination, the originating agency requested an addendum.  See VA Form 21-2507 (May 2017).  The request asks the April 2017 VA examiner to opine as to whether the Veteran’s robotic assisted laparoscopic abdominal sacrocolpopexy is a separate condition that is not related to the service-connected condition or if it is at least as likely as not (50 percent or greater probability) proximately due to or the result of the cystitis.  Although the originating agency clearly obtained the addendum based on its inclusion in the May 2017 Statement of the Case, the Veteran’s claims file does not include a copy of the May 2017 medical opinion addendum.  As indicated above, the question posed by the originating agency does not address the matter of aggravation.  
Therefore, having carefully reviewed the record, the Board concludes that remand is necessary to both associate with the claims file a copy of the May 2017 medical opinion addendum and to request another addendum on the full question of secondary service-connection, including aggravation.
The matter is REMANDED for the following action:
1. Obtain updated relevant treatment records.

2. Associate with the claims file a copy of the May 2017 VA medical opinion addendum.

3. Obtain a new addendum opinion from an appropriate clinician regarding whether the Veteran’s cystocele and/or weakened pelvic floor is at least as likely as not related to service-connected cystitis including whether cystocele/weakened pelvic floor is proximately due to service-connected cystitis or aggravated beyond its natural progression by service-connected cystitis.  Based on a review of the record (subjective complaints and objective findings), provide a full description of the all signs and symptoms associated with service-connected cystitis.  A complete rationale for the medical opinion is required.  The clinician should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s).  If an opinion cannot be expressed without resort to speculation, the clinician should so indicate and discuss why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge.
 
C.A. SKOW
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	D. Cheng, Associate Counsel