Citation Nr: 18153950 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 14-35 229 DATE: November 28, 2018 ORDER Entitlement to service connection for erectile dysfunction, to include as secondary to posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for tinnitus is remanded. FINDING OF FACT The Veteran’s erectile dysfunction is neither proximately due to nor aggravated beyond its natural progression by his service-connected PTSD, and is not otherwise related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for service connection for erectile dysfunction are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably in the United States Marine Corps from March 1954 to March 1957, and in the United States Navy from March 1959 to August 1963. The matters are before the Board of Veterans’ Appeals (Board) on appeal from a July 2012 decision of a Department of Veterans Affairs (VA) Regional Office (RO). In his October 2014 VA Form 9, Appeal to the Board of Veterans Appeals, the Veteran requested a Board hearing at a local office. In formal correspondence to the Board in January 2018, the Veteran withdrew his hearing request. This appeal will proceed based on the evidence of record. The Board notes that the Veteran’s claim for an acquired psychiatric disorder is no longer on appeal. In a September 2014 rating decision, the RO awarded service connection for PTSD, evaluated as 30 percent disabling, effective August 22, 2011. As such, the appeal has been satisfied and a claim for an acquired psychiatric disorder is not before the Board. I. Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. § 3.159. The Veteran has not raised any issues with the duties to notify or assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board"). II. Entitlement to Service Connection for Erectile Dysfunction Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran contends that his erectile dysfunction is caused by medication prescribed to help manage his service-connected PTSD. The question for the Board is whether the Veteran’s erectile dysfunction is proximately due to or the result of, or is aggravated beyond its natural progress by his service-connected PTSD. Specifically, the Veteran contends that his erectile dysfunction is a side effect of Prozac, which the Veteran was prescribed to manage his PTSD briefly in 2003. The Board notes that medical treatment records reflect that the Veteran was prescribed Prozac in June 2003. In August 2003, the Veteran stated that he was no longer taking Prozac as prescribed and had stopped taking it roughly two months prior. The Veteran does not contend, and the evidence of record does not show that the Veteran has taken Prozac since 2003. The Board concludes that, while the Veteran currently suffers from erectile dysfunction, the preponderance of the evidence is against finding that the Veteran’s erectile dysfunction is proximately due to or the result of, or aggravated beyond its natural progression by his service-connected PTSD, to include from medications taken for the disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The June 2014 VA examiner opined that the Veteran’s erectile dysfunction is instead due to his Peyronie’s disease, due to the marked abnormal curvature of the penis when erect. The rationale was that the Veteran reported erectile dysfunction around the same time as the onset of his diagnosis of Peyronie’s disease, and the Veteran’s specific symptoms are a direct result of his Peyronie’s disease. The examiner noted that the Veteran was currently taking citalopram hydrobromide and had in the past taken Prozac and Seroquel for his service-connected psychiatric disability. The examiner opined that while medications such as these can affect sexual function, antidepressants, including Prozac, are not known to cause the specific symptoms the Veteran experiences and are not risk factors for the development of Peyronie’s disease. While the Veteran believes his erectile dysfunction is proximately due to or the result of medications taken for his service-connected disability, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the genitourinary system. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the June 2014 VA medical opinion. Service connection may also be granted on a direct basis; however, the Veteran does not contend, and the evidence of record does not show that there was any in-service injury, event, or disease that caused the Veteran’s erectile dysfunction forty years after his separation from service. The preponderance of the evidence is against finding that the Veteran’s erectile dysfunction is related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Accordingly, the Board finds that service connection for the Veteran’s erectile dysfunction is denied. REASONS FOR REMAND Entitlement to service connection for tinnitus is remanded. The Veteran contends that he is entitled to service connection for tinnitus as secondary to his service-connected PTSD, as a side effect of his PTSD medication. The Veteran was prescribed Prozac in June 2003 for his psychiatric disorder, which was later diagnosed as PTSD. The evidence of record also shows that the Veteran has been prescribed Seroquel and citalopram hydrobromide for his PTSD. In September 2014, a VA examiner provided a medical opinion as to whether tinnitus can be a side effect of the medication Prozac. The examiner noted that the Veteran’s tinnitus could not be caused or aggravated by his service-connected PTSD as a side effect of Prozac because his complaints of tinnitus predate his June 2003 Prozac prescription. However, the examiner failed to consider whether the Veteran’s tinnitus could be a side effect of other medications prescribed to the Veteran for his PTSD, including Seroquel and citalopram hydrobromide. Thus, the Board finds that the September 2014 VA opinion as to a secondary service connection for tinnitus is inadequate. Additionally, regarding whether tinnitus is directly related to the Veteran’s service, in a July 2014 VA audiological examination, the examiner opined that the Veteran’s tinnitus was less likely than not related to his in-service noise exposure because forty years had passed between the Veteran’s separation from service and the onset of his tinnitus. The evidence of record shows that the Veteran had not complained of tinnitus at the time of his separation from service. When regulatory requirements for a disability are not shown at separation from service, service connection may still be established through probative evidence that the current disability is causally related to service. See Hensley v. Brown, 5 Vet. App. 155, 159-60 (1993); see also 38 C.F.R. § 3.303(d). The July 2014 VA medical opinion was based mainly on the lack of tinnitus on separation and the absence of complaints for forty years. The July 2014 VA examiner did not provide a clear rationale for the conclusion that noise exposure in service did not cause a delayed onset of tinnitus. The Board finds the July 2014 medical opinion inadequate as to the theory of entitlement for direct service connection for tinnitus. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period of September 2014 to the present. Contact the Veteran and afford him the opportunity to identify or submit any pertinent evidence in support of his claim, to include any records of any private treatment, specifically from the Veteran’s private primary care physician. Based on his response, attempt to procure copies of all records which have not been obtained from identified treatment sources. If any of the records requested are unavailable, clearly document the claims file to that effect and notify the Veteran of any inability to obtain these records, in accordance with 38 C.F.R. § 3.159(e). 2. After any records obtained have been associated with the electronic claims file, schedule the Veteran for a VA examination with a clinician with appropriate expertise in order to assess the nature and etiology of the Veteran’s tinnitus. The electronic claims folder must be made available to the examiner in conjunction with this review. After completing all indicated tests and studies, the examiner is to answer the following questions: A) Is it at least as likely as not (a 50% or greater probability) that the Veteran’s tinnitus is related to his service, to include noise exposure therein? B) Is it at least as likely as not (a 50% or greater probability) that the Veteran's tinnitus was caused by any of the Veteran's service-connected disabilities, including as a side-effect of any medication prescribed for any service-connected disability: (i) right eye choroid scars and anterior uveitis with recent oculotoxoplasmosis; (ii) PTSD; (iii) low back pain associated with malunion of fracture of left tibia and fibula ¾ inch shortening (now ½ inch) with some ankle disability; (iv) malunion of fracture of left tibia and fibula ¾ inch shortening (now ½ inch) with some ankle disability? C) Is it at least as likely as not (a 50% or greater probability) that the Veteran's tinnitus was aggravated (that is, any increase in severity beyond the natural progress of the condition as shown by comparing the current disability to medical evidence created prior to any aggravation) by any of the Veteran's service-connected disabilities, including from medication prescribed for any service-connected disability: (i) PTSD; (ii) low back disability; (iii) malunion of fracture of left tibia and fibula shortening with some ankle disability; (iv) right eye choroid scars and anterior uveitis with recent oculotoxoplasmosis? If the Veteran's current tinnitus has been aggravated by any of his service-connected disabilities, including from medication taken for any service-connected disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. The examiner must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K Pak, Associate Counsel