Citation Nr: 18141578
Decision Date: 10/11/18	Archive Date: 10/10/18

DOCKET NO. 13-24 501
DATE:	October 11, 2018
ORDER
Entitlement to service connection for a bilateral knee disorder, status post-left arthroscopy, is denied.
Entitlement to service connection for a bladder disorder, including urine incontinency, and to include as due to service-connected lumbar spine disorder, is denied.
(The issues of entitlement to service connection for a cervical spine disorder and bilateral foot disorder will be the subject of a separate Board decision)
FINDINGS OF FACT
1. The weight of the evidence is against a finding that the currently diagnosed bilateral knee disorder had its onset in active service or is causally connected to active service or due to or chronically worsened by a service-connected disability.
2. The weight of the evidence is against a finding that a bladder disorder, including urine incontinency, had its onset in active service, or is causally connected to active service, or due to or chronically worsened by the service-connected lumbar spine disorder.
CONCLUSIONS OF LAW
1. The criteria for entitlement to service connection for bilateral knee disorder have not been met.  38 U.S.C. §§ 1101, 1131, 1112, 1137, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.307(a), 3.309(a) (2017).
2. The criteria for entitlement to service connection for a bladder disorder, including urine incontinence, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303, 3.310.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The undersigned noted on the record of the Board hearing that the Veteran intended to withdraw his appeal of the issue of the bilateral knee disorder. See 06/12/2018 Hearing Testimony, P.1. Afterward, however, no findings were made to show that the Veteran fully understood the consequences of withdrawing the appeal of the issue. See Acree v. O’Rourke, 891 F.3d 1009 (Fed. Cir. 2018). Hence, the appeal of the issue is not deemed to have been withdrawn, and the Board addresses the issue below rather than dismissing it.
Service Connection
Generally, to establish service connection, a veteran must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303.
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).
Arthritis is presumed to have been incurred in service if manifested to a compensable degree within one year of separation from service. This presumption applies to veterans who have served 90 days or more of active service during a war period or after December 31, 1946. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). 
Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza elements in a claim involving a listed chronic disease is through a demonstration of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331, 1336-38 (Fed. Cir. 2013). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a chronic disease was “noted” during service or within the applicable presumptive period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology.
A disability which is proximately due to or the result of a service-connected injury or disease shall be service connected. 38 C.F.R. § 3.310. Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439 (1995).
In order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998).
“Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology.” Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (distinguishing between competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”).
In relevant part, 38 U.S.C. § 1154 (a) requires that VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). A layperson is competent to report on the onset of disability and, when applicable, continuity of his or her current symptomatology. See Layno, 6 Vet. App. at 470 (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient to establish a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007).
When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether an appellant’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011).
When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).
The Board acknowledges that the Veteran is fully competent to testify to the history of his disorders as he experienced them, to include the date of onset of his symptoms and the specific symptoms he experienced. 38 C.F.R. § 3.159(a)(2).  Nonetheless, all competent evidence must be tested for credibility and weight, if found credible.
1. Entitlement to service connection for bilateral knees
Service treatment records (STRs) dated in June 1980 note the Veteran’s complaints of right knee pain of one month’s duration. Physical examination was negative, and the examiner assessed functional pain. He was instructed to apply heat and was returned to duty. See 12/14/1982 STR-Medical, P. 40. The Veteran waived a physical examination at the time of his separation. Id., P. 15.
There is no indication that the Veteran complained of any knee-related symptoms at a 1983 VA examination for low back complaints. See 04/01/1983 VA Examination. In January 2009, the Veteran applied for service connection for a bilateral knee disorder claimed as due to his service-connected lumbar spine disability. See 01/23/2009 VA 21-4138. The April 2011 examination report (04/15/2011 VA Examination) reflects that the examiner reviewed the claims file as part of the examination. The Veteran reported complaints of bilateral knee pain, left greater than right, and that he underwent a left knee surgical procedure in 2004. The examiner noted that x-rays were read as having shown degenerative changes in both knees, which was included in the diagnoses. Based on the review of the Veteran’s records, the lay reported history, and the objective findings on clinical examination, the examiner opined that the Veteran’s knee disorder was not related to his active service. The examiner reasoned that the Veteran’s knee complaints started well after his active service, the sole in-service complaint of knee pain was more of a generalized pain that was not specific and was mentioned in passing. The examiner noted that no specific diagnosed knee condition was entered. The examiner also opined that the knee disorder was not related to the low back disability, but did not provide a rationale. Id., P. 7-8. Because there were areas on which the RO needed clarification, another examination was arranged.
The March 2013 examination report (03/29/2013 VA Examination) reflects that the examiner reviewed the claims file as part of the examination. The examiner took note of the June 1980 in-service complaint of right knee pain and the post-service motor vehicle accidents (MVA) in which the Veteran was involved. A 2013 MRI examination of the right knee revealed a torn meniscus. The examiner entered a diagnosis of chondromalacia patella of each knee. Id., P. 15. The Veteran reported that he banged both of his knees when fell off a tank during his active service. He sought treatment, x-rays were taken, and he was told he would have to cope with it. His knees have bothered him ever since. At the time of the examination, he was on a waiting list for repair of the right meniscus, and he could not straighten the left knee all the way since his last accident and ensuing surgery for a tibial fracture. This examiner noted that x-rays taken for the examination did not show degenerative changes. The MRI request notes that the left knee was twisted and severely contused after the July 2012 MVA. Based on the review of the Veteran’s records, his lay reported history, and the examination findings, the examiner opined that it was not at least as likely as not that the Veteran’s bilateral knee chondromalacia was causally connected to his active service, caused by the lumbar spine disability, or aggravated by it. The examiner noted that the STRs noted one instance of right knee pain, and none for the left knee. The examiner noted further that the Veteran did not complain of knee problems in 1983; and, that the chondromalacia pre-dated the July 2012 MVA. The examiner observed that the knee x-rays showed enthesopathies across each patella, which are not associated with direct trauma. They are called “traction spurs,” and would not be expected from a single trauma but are commonly associated with chronic strain. (Quotes in original) The examiner opined that chondromalacia patella is extremely common, and that it tends to worsen with age. Further, the type work the Veteran formerly did in heating and air conditioning placed a lot of stress on his knees, and it may have caused the disorder. The examiner noted that the medical literature did not support a causative or aggravating connection between chondromalacia patella and other conditions, such as the Veteran’s lumbar spine disability. Hence, the negative nexus opinion. Id., P. 65-67.
The evidence of record shows that the Veteran has a currently diagnosed bilateral knee disorder, so the first requirement for service connection is satisfied. 38 C.F.R. § 3.303. The Board finds, however, that the preponderance of the evidence is against in-service onset of either his symptoms or the diagnosed disorder. As two VA examiners noted, there was only one instance of in-service right knee pain, and no disorder was diagnosed. Further, there is no persuasive evidence of continuous symptoms since separation from active service. Non-VA records note that, in January 1984, the Veteran was struck by a slow-moving vehicle while a pedestrian. He was knocked down, and the right leg was bent under the bumper. He complained of tingling below the knee, and there was no indication of a history of prior knee complaints. Knee x-rays were negative. Hence, this is evidence that arthritis had not manifested within one year of his separation from active service. See 08/22/2008 Medical Treatment-Non-Government Facility, P. 4, 28. The Veteran’s non-VA treating physician noted that when he first treated the Veteran in 2001 following a MVA, traumatic arthritis was noted in each knee. The physician’s emphasis was a nexus opinion for the Veteran’s lumbar spine disability, but there still was no indication of a report by the Veteran of in-service knee complaints. See 07/28/2008 Medical Treatment-Non-Government Facility, P. 1.
Further, the examiners opined that there was no causative connection between the knee disorder and the Veteran’s service or his service-connected disability. The Board notes that the examiner at the 2009 examination did not provide a rationale for the opinion, nor was aggravation by the low back disability addressed. That deficiency was cured by the 2013 examination. There, the examiner reviewed the claims file, examined the Veteran, considered the Veteran’s lay reported history, and provided a rationale for the opinions rendered. In addition to the absence of a direct causative connection, the examiner also opined that the bilateral knee disorder was not caused or aggravated by the service-connected lumbar spine disability. Hence, despite the presence of a currently diagnosed disorder and service connection for the lumbar spine, there is no causative or aggravating nexus.
Concerning direct service connection, the 2013 examiner noted that the Veteran did not voice any knee complaints at the April 1983 examination of his back or file a claim for his knees. The Board attaches minimal weight to that part of the examiner’s rationale.  See Manio v. Derwinski, 1 Vet. App. 140, 144 (1991). Nonetheless, it does not substantively impact the overall weight to be accorded to the examiner’s rationale, as it was only one basis he provided for the negative nexus opinion. Hence, the Board finds the opinions highly probative and attaches significant weight to it. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Thus, the Board finds that the preponderance of the evidence is against the claim on a presumptive, direct, and secondary basis. 38 C.F.R. §§ 3.303, 3.307(a), 3.309(a), 3.310.
2. Entitlement to service connection for bladder disorder
At the 2018 Board hearing, the Veteran testified that his bladder symptoms started in active service after he fell from a tank and injured his back. He testified that he could not control it because he could not feel it; the symptoms go away but they return. See 06/12/2018 Hearing Testimony.
In an October 1980 Report of Medical History the Veteran denied any history of frequent or painful urination. The Report of Medical Examination reflects that the Veteran’s genitourinary system was normal. See 12/14/1982 STR-Medical, P. 10, 13.  
In an October 1983 neurogenic consult bladder complaints were denied.
In a July 2007 letter, the Veteran’s non-VA treating physician, R.J.G., M.D., reported that he first treated the Veteran in 2001 for injuries sustained in a MVA. He noted the Veteran’s problem list to include lumbar spondylosis with bilateral L4-5 foraminal stenosis, neurogenic bladder and bowel, and neurogenic erectile dysfunction. He opined that, given the Veteran’s reported history of persistent complaints and documented neurological findings, a retroactive analysis led him to conclude that the Veteran’s in-service back injury resulted in an undiagnosed chronic lumbar disc injury with herniation, and evolved to include symptoms of neurogenic bladder and control losses (cauda equine syndrome) that were subsequently aggravated by subsequent traumas and aging. See 07/28/2007 Medical Treatment-Non-Government Facility, P. 1, 3.
At a 2009 VA spine examination, the Veteran reported some urine incontinence. Neurological examination revealed positive straight leg raising, hypoactive reflexes, at the knees, equal ankle reflexes, and normal sensation throughout. The examiner diagnosed lumbar degenerative disc disease but did not further address the report of urinary incontinence. See 01/20/2009 VA Examination. The RO arranged a urological examination.
The examination report (02/10/2010 VA Examination) reflects that the purpose of the examination was to assess the Veteran’s complaints of fecal incontinence secondary to his low back disability. The examiner noted that he conducted a thorough review of the claims file and noted that the Veteran had been involved in multiple MVAs, as well as a work injury. The Veteran reported complaints of low back pain and numbness that resulted in his inability to feel that a bowel movement was coming on. It resulted in large volume fecal incontinence which the Veteran reported had been going on for the last 3 to 4 years. The Veteran reported only rare instances of urinary incontinence, as when he began to feel that he was wetting himself, he could control it and go to the bathroom and void. He denied any large volume incontinence. Dr. G had recommended back surgery, but he declined due to the risk of paralysis. The Veteran did not use any assistive devices whatsoever. He reported fecal incontinence about 1 to 2 times a day where he has to change his clothes. He denied fecal incontinence while asleep, but it had happened while lying down when he was in a position that induced a bowel movement. He reported ongoing chiropractic treatment for his back since 1980 but without significant relief or improvement. 
Physical examination revealed no abnormality on palpation of the penis, testicles, epididymitis, and spermatic cord. Inspection of the anus revealed no abnormalities; digital examination of the rectal walls revealed normal anatomic structure with optimal sphincter tone. Prostate was normal, and sensation was intact. Abdominal examination was normal, as were strength and deep tendon reflexes. The examiner diagnosed DDD of the lumbar spine with no indication of progression of neurological deficits that would cause bowel/fecal or urinary incontinence. The examiner noted that his examination of the Veteran did not reveal any evidence of dysesthesias, saddle anesthesia, or sensory deficits. As a result, the examiner opined that the Veteran’s claimed fecal and urinary incontinence was not due to his lumbar spine DDD; and, to opine on any causative relationship with the Veteran’s active service would be speculative. The Board interprets the examiner’s statement to mean that she found no evidence on which to link the Veteran’s claimed symptoms to his active service. The examiner noted further that he had requested the results of an MRI examination conducted in 2009 to see if it had any bearing on the Veteran’s complaints. 
The April 2011 VA joints examination report (04/15/2011 VA Examination) reflects that the examiner reviewed the claims file, to include the February 2010 genitourinary examination report, and Dr. G’s treatment notes which the Veteran provided. In addition to complaints of constant low back pain, the Veteran reported bowel and bladder problems, but he denied any sudden loss of bladder or bowel function. The examiner noted that the Veteran’s reported dysfunction appeared to be activities related. Id., P. 3-4. Neurological examination revealed intact motor and sensory function. Reflexes were 2+, and there was mild weakness of the RLE. The Veteran described dullness of sensation of the left thigh and RLE. The examiner noted that a 2007 MRI examination revealed mild degenerative changes from L3-4 to L5-S1 with foraminal stenosis at L4-5 and L5-S1. An EMG was negative for electrodiagnostic evidence of lumbar radiculopathy of either LE. The examiner diagnosed lumbar DDD with lumbar radiculitis bilaterally.
The May 2012 general examination report (05/04/2012 VA Examination) reflects that the Veteran reported intermittent stool incontinence which he attributed to loss of sensation due to pain. Rectal examination, however, revealed rectal tone to be within normal limits. The examiner that a 2011 EMG was negative for cervical or lumbar radiculopathy, which the examiner noted was markedly inconsistent with the clinical findings on examination of non-anatomic distribution of sensory deficits. The examiner opined that it was not at least as likely that the Veteran’s claimed bowel incontinence was due to his lumbar radiculopathy, as the EMG findings did not support the Veteran’s subjective symptoms. Id., P. 20, 25, 33, 37, 52, 54.
The March 2013 examination report (03/29/2013, 2nd Entry, P. 8-24) reflects that the examiner reviewed the claims file and noted a December 2011 diagnosis of record of urinary incontinence not otherwise specified (NOS), and she also noted that the reported the onset of symptoms as 1980. The Veteran reported in-service leaking of urine and stool about once a week when he bent forward. He also reported constant numbness at his low back and legs since his separation from service. The Veteran further reported that his bladder emptied normally when he urinated, and that when he bent forward sometimes he would leak a little urine about 3 to 4 times a day. He tried to avoid large leakage by urinating 4 to 5 times a day. He denied use of an incontinence pad. The Veteran reported further that Dr. G told him his symptoms were due to a nerve getting pinched when he bent over; Dr. G referred him to a urologist who told him that his urinary system was normal otherwise; and, that Dr. G also referred him to a gastroenterologist who assessed his rectal tone as normal. The Veteran could not recall the name of the urologist or the gastroenterologist. He refused a rectal examination. (Quotes in original). Id., P. 17. He also refused an undressed sensory examination of the buttocks or thighs. A sensory examination of those areas performed through his pants revealed normal findings in the thighs and lower legs; DTRs were 1+ at the knees and ankles bilaterally; and there were no signs of upper motor neuron abnormality at the LEs. The examiner asked the Veteran about the normal anterior thigh sensory examination and his reported history of numbness, and the Veteran responded that the sensation in that area was actually normal on the day of the examination. The examiner noted that a January 2013 MRI examination was read as having shown no significant change as compared to the February 2010 MRI examination. Id., 18-19. 
Based on the review of the Veteran’s claims file and medical records, the Veteran’s lay reported history, the results of the clinical examination, and the medical literature, the examiner opined that it was not at least as likely as not that the Veteran’s intermittent urine incontinence was not causally connected to the Veteran’s active service, nor was it due to or chronically worsened by the service-connected lumbar spine DDD with bilateral LE radiculitis. The examiner’s reasoned that the January 2013 MRI examination did not show any compromise of the sacral roots as would be expected for a spinal cause of bladder dysfunction, which she noted was frequently called cauda equine syndrome; the EMG did not show findings consistent with lumbar radiculopathy; hence, it was not as likely as not that the Veteran’s intermittent urine leakage was due to a neurogenic bladder, and that the cause was unclear. The examiner noted further, however, that the Veteran refused a rectal examination, and that a normal rectal examination would make it less likely that there is a spinal cause for the intermittent urine incontinence. The examiner also noted that, contrary to his report of onset of symptoms in 1980, a 2008 pain consult noted the Veteran’s denial of any bowel or bladder symptoms at that time. Id, P. 23-24.
At the Board hearing, the Veteran’s representative asserted that the referenced January 2013 MRI examination report was not in the records included in the claims file. The Board notes that the report is in fact included in Dr. G’s records, which were provided to the VA examiner. See 04/04/2013 Non-Government Facility, P. 5-6. Hence, the Board finds that there are no outstanding records on which the examiner relied in forming the negative nexus opinion.
In deciding this appeal, the Board must weigh the evidence and in so doing, may accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). The Board may favor the opinion of one competent medical expert over that of another, provided the reasons therefor are stated. Winsett v. West, 11 Vet. App. 420, 424-25 (1998). Further, the Board is not required to accord more weight to the opinion of a treating physician, see White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001), as the Court of Appeals for Veterans Claims has explicitly “rejected the broad application of the ‘treating physician rule’ that gives the opinions of treating physicians greater weight in evaluating veterans’ claims.” Van Slack v. Brown, 5 Vet. App. 499, 502 (1993) (citing Harder v. Brown, 5 Vet. App. 183, 188 (1993)); see Guerrier v. Brown, 7 Vet. App. 467 (1993). While the Board is not free to ignore the opinion of a treating physician, neither is it required to accord it substantial weight. See generally Guerrieri v. Brown, 4 Vet. App. 467, 471-73 (1993); Sanden v. Derwinski, 2 Vet. App. 97, 101 (1992).
At this juncture, the sole medical evidence that supports the Veteran’s lay assertions is Dr. G’s 2007 nexus opinion. For the reasons set forth below, the Board finds that the multiple opinions of the VA examiners as earlier discussed garner the greater weight.
First, Dr. G’s opinion clearly noted that he placed significant weight on the Veteran’s reports that his bowel and bladder symptoms started in service after his low back injury. (Emphasis added). See 07/28/2007 Non-Government Facility, P. 1-2. While Dr. G noted the STRs entries related to the Veteran’s complaints of low back pain, he failed acknowledge that none of those entries noted complaints of bowel or bladder issues, nor did he note the October 2010 examination that assessed the Veteran’s GU system and abdomen and viscera as normal. Dr. G noted the presence of bowel and bladder symptoms in 2001, and in 2003, when he noted that a neurosurgeon had opined that a cervical disc herniation and lumbar stenosis were the agents of the cauda equine syndrome.  However, it was not until the Veteran reported that his symptoms started immediately after the in-service injury that Dr. G identified that event as the genesis of the Veteran’s reported symptoms. Before, he attributed them to the 2001 MVA for which he initially treated the Veteran.
The Veteran testified at the hearing that he received chiropractic treatment in the 1980s for his symptoms but records of that treatment were no longer available. Dr. G in fact noted that treatment in the Veteran’s history. Dr. G notes a substantial history of post-service low back injuries, some work related, that began in 1981. Chiropractic treatment occurred in 1984 and 1989, with the latter being related to a 1984 injury. Although all of the noted treatment in the 1980s into the 1990s note low back pain and cervical and lumbar disc herniation (sciatica is first noted in 1989), Dr. G does not indicate that any of that past history included bowel or bladder involvement. Id., P. 2. The Board finds that it was only after the Veteran’s report that his symptoms started in service that Dr. G retroactively opined that his bladder and bowel issues were causally related to his lumbar spine disorder. Id., P. 3. 
It is not improper for a physician to rely on a patient’s history when opining on an etiology, but the reported history must be tested for accuracy. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Board finds that the other evidence of record outweighs the Veteran’s lay assertions of in-service onset of fecal or urinary involvement. Further, the preponderance of the evidence shows that the Veteran’s lay assertions of current incontinence are incredible.
The Board has already noted that the STRs, to include the October 1970, are silent as to any complaints of bowel or bladder issues. At the 1983 VA examination where the Veteran complained of severe low back pain, there were no noted complaints of bowel or bladder complaints, or radiculopathy. See 04/01/1983 VA Examination. As noted earlier, radiculopathy complaints appeared after the rash of MVAs in which the Veteran was involved. See 08/22/2008 Non-Government Facility. Further, the Veteran’s outpatient records constantly note his denial of bladder or bowel issues, urinary incontinence, or difficulty with starting or stopping his urine stream. See 08/11/2015 CAPRI, P. 2; 07/25/2016 CAPRI, P. 75; 11/10/2016 CAPRI, P. 219. In August 2016, the Veteran’s records noted his requests that his treating VA physicians attribute his claimed urine incontinence to a disc herniation. The VA neurologist noted that a July 2015 MRI showed a large protrusion that was not found during surgery five months later, and that it was not unusual for herniations seen earlier to not be present later. Nonetheless, the neurologist opined that the noted herniation at left L4-5 with inferior migration was not large enough to explain incontinence. Hence, he could not support the Veteran’s assertion. See 11/15/2017 CAPRI, P. 178-180. In October 2017 and April 2016, the Veteran denied urinary or fecal incontinence. Id., P. 10, 172. If such symptoms were present between 2001 and 2007, absent the Veteran’s lay reports, Dr. G, and the specialists to whom he referred the Veteran, attributed them to the 2001 MVA. The Board also notes the fact that over the years the Veteran’s claimed symptoms morphed from fecal and urine incontinence to just urine incontinence. Nonetheless, the evidence is against both.
Given the above, the Board finds against the claim.  Indeed, the objective medical findings have not confirmed the Veteran’s claimed lay subjective symptoms; and, to the extent that they are or may have been present, the preponderance of the evidence shows that they did not have onset in service, they are not otherwise causally connected to active service, nor are they due to or chronically worsened by the service-connected lumbar spine disability. 38 C.F.R. §§ 3.303, 3.310. 
The Board acknowledges the Veteran’s lay opinion that he has urinary incontinence that is directly connected to his active service as well as his service-connected lumbar spine disability. See, e.g., the Hearing testimony. When considering whether lay evidence is competent, the Board must determine on a case-by-case basis whether a claimant’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Board finds that opining on the etiology of a urological or gastrointestinal disorder or symptoms requires medical training. See 38 C.F.R. § 3.159(a). There is no evidence that the Veteran has medical training. Hence, his personal opinion on the issue has no probative value.

 
Eric S. Leboff
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	W.T. Snyder