Citation Nr: 18154930 Decision Date: 12/04/18 Archive Date: 11/30/18 DOCKET NO. 16-19 558A DATE: December 4, 2018 ORDER The claim for entitlement to service connection for depression, as secondary to service-connected residuals of circumcision is reopened; to this limited extent only, the appeal is granted. The claim for entitlement to service connection for residuals from a scorpion sting to the male reproductive organ is reopened; to this limited extent only, the appeal is granted. The appeal for the entitlement to service connection for headaches is dismissed. Service connection for residuals from a scorpion sting to the male reproductive organ is denied. Service connection for depression is granted Entitlement to service connection for bilateral hearing loss is denied. An initial rating in excess of 10 percent for tinnitus is denied. REMANDED Entitlement to service connection for sleep apnea, to include as secondary to service-connected tinnitus, is remanded. Entitlement to a compensable rating for residuals of circumcision is remanded. Special monthly compensation (SMC) for the loss of use of a creative organ is remanded. FINDINGS OF FACT 1. A May 2005 Board decision denied service connection for depression (claimed as a nervous condition), as secondary to service-connected residuals of a circumcision. 2. An October 1998 Board decision denied service connection for residuals from a scorpion sting to the male reproductive organ. 3. Evidence received since the October 1998 and May 2005 decisions is new and relates to an unestablished fact necessary to substantiate the claim. 4. Prior to the promulgation of a decision in the appeal, the Veteran withdrew his service connection claim for headaches at the June 2018 Board hearing. 5. The Veteran does not have residuals from a scorpion sting to the male reproductive organ. 6. Resolving reasonable doubt in the Veteran’s favor, depression had onset in service and is also related to service-connected residuals of circumcision. 7. The Veteran does not have a hearing loss disability for VA disability purposes. 8. The Veteran’s tinnitus is assigned the maximum schedular rating. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal for entitlement to service connection for headaches have been met. 38 U.S.C. § 7105(b)(2), (d)(5); 38 C.F.R. § 20.204. 2. The criteria for reopening a previously denied claim of service connection for depression, as secondary to service-connected residuals of a circumcision, have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for reopening a previously denied claim of service connection for residuals from a scorpion sting to the male reproductive organ have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. The criteria for service connection for residuals from a scorpion sting to the male reproductive organ have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for depression are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for service connection for hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a), 3.385. 7. The criteria for an initial rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1975 to August 1979. These matters are before the Board of Veterans’ Appeals (Board) on appeal from the October 2013 and May 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). Additional evidence was added to the file following the issuance of the statement of the case in April 2016. This evidence is not relevant and essentially duplicative of evidence that had been previously submitted and considered by the Agency of Original Jurisdiction (AOJ); a waiver is not necessary. See 38 C.F.R. § 20.1304. In June 2018, the Veteran testified before the undersigned Veterans Law Judge at a hearing. A copy of the transcript is associated with the Veteran’s claims file. Withdrawn Claim The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. Id. In the presence of his representative and after being sworn in, the Veteran testified during the June 2018 Board hearing that he wished to withdraw his appeal for the claims of service connection for headaches. A written transcript of the Veteran’s testimony is of record. Thus, there remains no allegations of errors of fact or law with respect to this issue on appeal. Accordingly, the Board does not have jurisdiction to review the appeal and it is dismissed. New and Material Evidence At the outset, the Board finds the evidence submitted for the May 2012 claim tends to substantiate an element of the previously adjudicated matter, claimed as a nervous condition. Accordingly, the claim for depression has been characterized as a claim to reopen. See Velez v. Shinseki, 23 Vet. App. 199, 204 (2009) (quoting Boggs v. Peake, 520 F.3d 1330, 1337 (Fed. Cir. 2008)). The Board further notes that in August 2016, additional service personnel records were associated with the claims file. Upon review, they are not relevant to the claims on appeal and as such, 38 C.F.R. § 3.156(c) is not for application. VA may reopen and review a claim, which has been previously denied, if new and material evidence is submitted by or on behalf of the Veteran. 38 U.S.C. § 5108. 1. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for depression, as secondary to service-connected residuals of a circumcision. Service connection for depression, as secondary to service-connected residuals of a circumcision (claimed as a nervous condition) was last denied in a May 2005 Board decision. 38 U.S.C. § 7104. Board decisions are final when issued. 38 C.F.R. §§ 3.104, 20.1100. In May 2012, VA received an application to reopen the claim. Upon review of the record, the Board finds that new and material evidence sufficient to reopen the claim has been obtained. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New evidence in the forms of VA medical records, a June 2014 private Disability Benefits Questionnaire (DBQ), the September 2013 and October 2016 VA examination reports, and the June 2018 Board hearing testimony pertain to causal nexus; a previously unestablished fact need to substantiate the claim. 2. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for residuals of a scorpion sting to the male reproductive organ. Service connection for residuals of a scorpion sting to the male reproductive organ was last denied in an October 1998 Board decision. 38 U.S.C. § 7104. Board decisions are final when issued. 38 C.F.R. §§ 3.104, 20.1100. In May 2012, VA received an application to reopen the claim. Upon review of the record, the Board finds that new and material evidence sufficient to reopen the claim has been obtained. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Since the Board decision, VA medical records, private medical records, the February 2001, April 2001, September 2013, and April 2016 VA examination reports, the September 2004 RO hearing testimony, and the June 2018 Board hearing testimony have been added to the file. This evidence pertains to a current disability and causal nexus; previously unestablished facts needed to substantiate the claim. As new and material evidence has been received, the appeal is reopened. Having reopened these claims, the Board will proceed to address the underlying merits. The Veteran is not prejudiced by this action as the RO has also done so. Hickson v. Shinseki, 23 Vet. App. 394 (2010). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Generally, in order to establish 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 Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). 3. Entitlement to service connection for residuals of a scorpion sting to the male reproductive organ. The Veteran contends that during basic training in Parris Island, South Carolina, in 1975, he was stung on the male reproductive organ by a scorpion, and that he currently has residuals from the sting. For the reasons that follow, the Board finds that service connection is not warranted. Service treatment records are negative for any complaints, findings, or treatment for a scorpion sting to the male reproductive organ. This is not to say that he was not seen for complaints of or treatment for conditions relating to the male reproductive organ. On September 14, 1975, the day he contended the in-service event occurred, the Veteran was seen for soreness of the male reproductive organ and for burning upon urination; he was diagnosed with balanitis (inflammation of the foreskin). There was no record of a scorpion sting. He was prescribed an antibiotic and was scheduled for a follow-up visit two days later. At the follow-up visit, the clinician noted mild redness of the glans and “mild [illegible] to the head ‘due to filthy.’” The clinician noted that the Veteran “doesn’t [pull the] skin back when voiding” and observed that the male reproductive organ was “progressively getting better.” He was then advised to pull the skin back when voiding and was prescribed an additional antibiotic ointment for treatment. In January 1976, the Veteran requested possible circumcision. The record noted that there were no present difficulties with his prepuce (foreskin) and he was keeping himself clean. A July 1976 physical examination showed a normal genitourinary system and that he was not circumcised. A November 1976 record provided a referral to urology after discussing circumcision; he had no reported medical problems. In February 1978, the Veteran related a history of painful sexual intercourse. The examination was normal and he was given a consult for elective circumcision. A March 1978 psychiatric evaluation showed that he experienced dyspareunia since adolescence that caused frustration, and a urology consultation revealed the cause to be a restricted foreskin. That same month, he consented to elective circumcision, which was performed in April 1978. The July 1979 separation examination noted his circumcision procedure and a normal genitourinary system, on examination. In a post-service March 1980 VA treatment record, a clinician noted “dry, peeling skin close to the tip” of his male reproductive organ and that the area was inflamed, but a diagnosis was not provided. In May 1980, he was seen for “annular crusted lesions on [the] shaft.” The clinician opined “probable genital herpes.” An October 1980 VA clinical record showed that he reported concern about his sutures coming out from the surgical area. The clinician noted that the site was well-healed, it was not infected, and noted there was no need for a follow-up visit. He was seen in April 1991 for “chronic recurrent penile lesions” that usually erupted, were painful, and formed scabs. At a follow-up appointment with a VA dermatologist, the clinician did not provide any diagnosis. At another April 1991 VA consultation, the clinician diagnosed the Veteran with “frenular adhesion.” During the July 1991 RO hearing, the Veteran testified that on September 14, 15, and 16, 1975, he was treated for a scorpion sting to the male reproductive organ, a circumcision was then performed, that the procedure was performed in a substandard manner, and that he had problems with abscesses forming and with sutures coming out since the procedure. Pursuant to a February 1996 Board remand, the Veteran was afforded a VA examination in April 1996. He reported he had a severe reaction with edema of the foreskin of his male reproductive organ after being stung by a scorpion in 1978, which required circumcision. He reported problems with ‘skin bridges’ ever since the surgical procedure. On examination, the examiner found numerous hyperpigmented, flat-topped, coalescing, papules encircling the shaft of the male reproductive organ. He was diagnosed with hypertrophic scars secondary to his circumcision procedure. Private treatment records showed he was seen for skin bridges secondary to his circumcision procedure. The provider found an ulcerated lesion that was healing without infection at the suture site. At a May 1996 VA examination, the Veteran reported that the circumcision procedure was performed incorrectly as formation of ‘skin bridges’ occurred afterward. The examiner found that he had a normal male reproductive organ and that the circumcision appeared to have been performed adequately. However, there were several sites that appeared to be suture tracks. The examiner opined that the suture materials used dissolved at an inconsistent rate that led to an inadequate reabsorption problem. In September 1996, the Board remanded for clarification from the RO as to the adjudicative action regarding this claim. Subsequently, in a March 1998 rating decision, the RO granted service connection for residuals of a circumcision, based on skin bridges that rendered the Veteran’s male reproductive organ prone to occasional infection and irritation. In January 1997, the Veteran sought treatment for complaints of sutures popping out. The clinician found skin tags upon examination and diagnosed him with such, with an etiology tied to past surgical incision. A March 1997 private treatment record showed complaints of his skin bridges, but on examination, the clinician found ulcerated lesions that was healing without infection at the suture site. The Veteran underwent another VA examination in April 1997. The examiner found that his male reproductive organ was normal, and that the circumcised surgical area has multiple skin bridges where the area is clear, but had the potential for abscesses to form inside the tunnel of skin bridges. The Veteran also had some thinning of the skin. In October 1998, the Board denied the Veteran’s claim for service connection. The Board found that the competent medical evidence of record did not demonstrate a nexus between a scorpion sting and the currently-diagnosed conditions of the male reproductive organ. Rather, the medical evidence attributed the conditions to the circumcision during service, for which service connection was already established at that point. A private treatment record in December 1998 noted that the Veteran’s male reproductive organ had 2 small skin bridges as a result of a remote circumcision, which become painful and swollen. No evidence of inflammation was found. A November 1999 private treatment record diagnosed him with balanitis. At the February 2001 and April 2001 genitourinary VA examinations, the examiner noted that since the circumcision, he has had multiple, recurrent skin bridges. A scorpion sting incident was not mentioned. The examiner provided a diagnosis of skin bridges. A September 2013 VA examination provided a diagnosis for residuals of circumcision. The examiner found the male reproductive organ was normal upon examination. He was noted to be able to achieve erection with the aid of medication but the examiner agreed with the prior assessment that the etiology of the erectile dysfunction was not due to his circumcision procedure. Post-service VA treatment records show the Veteran has discussed being stung by a scorpion during service numerous times, but there are no residuals identified resulting from a scorpion sting. The records show that the Veteran identified residuals from a “botched circumcision.” A December 2015 treatment record showed findings of condyloma acuminatum (genital warts) on the shaft of the male productive organ and noted a history of lesions on the scrotum. There was no mention of a scorpion sting. In April 2016, the Veteran underwent another VA examination. Again, the examiner provided a diagnosis of residuals of a circumcision and not as due to a scorpion sting. Regarding the Veteran’s reported erectile dysfunction, the examiner found that it was not due to the service-connected residuals of a circumcision. At the hearing, the Veteran again asserted that he was stung by a scorpion in service, experienced swelling and constriction of the foreskin as a result, and has had chronic residuals complications. After a thorough review of the record, the Board finds that service connection is not warranted for the reasons stated below. Service treatment records do not reflect any report of, complaints of, findings, or treatment for a scorpion sting to the penis. While the Veteran sincerely believes that his foreskin constricted as a result of the scorpion sting during service, the objective findings demonstrate otherwise. Instead, the service treatment records showed that he requested discussion of possible circumcision in January 1976, November 1976, February 1978, and March 1978. The record showed that the Veteran elected circumcision. The March 1978 psychiatric evaluation showed that he experienced dyspareunia since adolescence that caused frustration, and a urology consultation revealed the cause to be a restricted foreskin. The etiology for the restricted foreskin was not due to a scorpion sting, but due to his dyspareunia. The July 1979 separation examination noted his circumcision procedure and a normal genitourinary system, with no mention of a scorpion sting or identified any residuals. During service and since separation from service, there have been no residuals identified from a scorpion sting. Instead, the record reflects that any resulting residuals have been from the April 1978 circumcision procedure, for which he is already service-connected. There is no competent evidence to the contrary. The Board acknowledges the Veteran’s assertion that he now suffers residuals as a result of his scorpion sting in service. Even assuming the credibility of the Veteran’s assertion that he sustained a scorpion sting to the male reproductive organ in service, which led to a restricted foreskin - that condition resolved once the April 1978 elective circumcision procedure was performed. The medical evidence and testimony of record all show that the remaining residuals are related to the circumcision procedure (i.e., skin bridges, reported erectile dysfunction) and not due to a scorpion sting. In fact, the VA treatment records reflect that the Veteran identified residuals from a “botched circumcision.” In short, he is already service-connected for symptoms related to the in-service circumcision procedure. To rate the same symptomatology separately under two identical diagnostic codes would constitute impermissible pyramiding. See 38 C.F.R. § 4.14. Given the above, the preponderance of the evidence is against the claim for service connection for residuals of a scorpion sting to the male reproductive organ is not warranted. There is no doubt to be resolved. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4.Entitlement to service connection for depression, as secondary to service-connected residuals of a circumcision, is granted. In May 2012, the Veteran filed a claim for service connection for depression secondary to ‘sexual difficulties associated with a penile problem.’ The Board finds that this claim was actually a claim of entitlement to service connection for a psychiatric disorder, however diagnosed, pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran was afforded a VA examination in September 2013 to assess the nature and etiology of his claimed psychiatric disorder. At the examination, a VA examiner provided diagnoses of history of polysubstance dependence (with 19 years of sobriety reported); adjustment disorder with mixed depression and anxiety; and personality disorder not otherwise specified with narcissistic traits. The examiner generally opined that the adjustment disorder with mixed depression and anxiety was not related to service or the circumcision therein. However, he also indicated that the Veteran experienced depression secondary to a lack of intimate relationships and his single status all his life. VA treatment records reflect diagnoses of depression. In May 2016, during the course of the appeal, the Veteran filed a claim for posttraumatic stress disorder/schizophrenia. At a VA examination in October 2016, a VA examiner reviewed the entire claims file and clinical history and provided a current diagnosis of schizoaffective/bipolar disorder type. Review of the examination report shows the Veteran examiner determined that the Veteran’s psychiatric symptoms of depression and depressed mood, are part of his now service-connected schizoaffective/bipolar disorder. The examiner specifically opined that: Review of records indicates that his symptoms have largely been attributed to mood disorders and/or anxiety, with some providers attributing the related psychosocial functioning difficulty and grandiosity to a Narcissistic PD (see 9-24-13 C&P exam by Dr. K.). It is only with a recent change in providers, that the delusional nature of his condition has been identified with a resulting change in his diagnosis to Schizophrenia Spectrum disorder. This writer is in agreement with the veteran's current provider, that his symptoms are primarily psychotic in nature. The examiner further concluded that: In conclusion, it is as likely as not that his change in behavior, executive functioning difficulty, distress over dyspareunia despite normal anatomy, lack on insight, and disorganized thoughts which first presented in the service are the first manifestations of his schizoaffective disorder. His schizoaffective disorder is therefore felt to be a continuation of the MH treatment that he first received in the service. Polysubstance dependence is in sustained remission and is therefore not contributing to his current symptoms or psychosocial functioning difficulty. Based on this examiner’s findings, which the Board finds highly persuasive, it appears that the depression the Veteran suffered from at the time of his 2012 claim was related to his mental problems that initially manifested in service, in part related to distress over dyspareunia (i.e. painful intercourse). Notably, the Veteran reported painful intercourse during service (which prompted the circumcision). Furthermore, he testified that he feels depression due to his circumcision residuals and how it has negatively impacted his intimate relationships. The Board finds him credible in this regard. The September 2013 VA examiner also noted that the Veteran experienced depression secondary to a lack of intimate relationships and his single status all his life. The Court of Appeals for Veterans Claims held in McClain v. Nicholson, 21 Vet. App. 319 (2007) that the requirement of a current disability is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim. Based on the evidence discussed, there is a current disability of depression. The 2016 VA examiner has essentially indicated that the depression is part of the manifestation of the currently-diagnosed schizoaffective/bipolar disorder type which had onset in service. The Veteran, through written argument, has essentially asserted the same. Thus, in order to resolve this appeal in a manner most favorable to the Veteran, the Board will resolve all reasonable doubt in his favor to find service connection is warranted for depression as it was present a separate diagnosis during the appeal and shown to be related to service and a service-connected disability. In effectuating this grant, the Board trusts that the RO will assign the proper effective date, which would appear to be the date of the claim (e.g. May 2012) considering Clemons, McClain supra. Finally, the Veteran is advised that while service connection for more than one psychiatric disorder is not precluded by law, service-connected psychiatric disorders are assigned a single rating under a general formula for rating mental disorders. See 38 C.F.R. § 4.130 (2007). 5. Entitlement to service connection for bilateral hearing loss is denied Service connection for hearing loss may be granted where there is credible evidence of acoustic trauma due to significant noise exposure in service, where post-service audiometric findings indicate that there is a hearing loss disability, and where there is a sound basis upon which to attribute the post-service findings to the in-service injury (as opposed to incurrent causes). See Hensley v. Brown, 5 Vet. App. 155, 157-59 (1993). For the purposes of the applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. “The threshold for normal hearing is between 0 and 20 [decibels], and higher thresholds indicate some degree of hearing loss.” Hensley, 5 Vet. App. at 157. The relevant question at issue is whether the Veteran has a hearing disability at present, as defined by 38 C.F.R. § 3.385, so as to meet the criteria for service connection for defective hearing. There is no competent evidence of hearing loss in either ear for VA purposes at any time during the appeals period. The Veteran was examined by VA and the diagnostic findings from the audiological examination in June 2014 failed to show a hearing loss for VA compensation purposes in either ear. 38 C.F.R. § 3.385 based on pure tone thresholds, in decibels, and speech audiometry revealed speech recognition ability scores provided for each ear. The examiner noted normal hearing in both ears. The audiological findings on the VA examination did not show an auditory threshold greater than 25 decibels at any of the relevant left ear frequencies or, speech recognition score less than 94 decibels in either ear. At the hearing before the undersigned, the Veteran testified that his hearing acuity had not worsened since that examination and that he had not received any further treatment or hearing aids. Given the lack of evidence showing that the Veteran has a hearing disability in either ear at present, as that term is defined in 38 C.F.R. § 3.385, service connection for hearing loss is not warranted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Increased Rating Entitlement to an initial rating in excess of 10 percent for tinnitus. The Veteran seeks a rating higher than 10 percent for his service-connected tinnitus. Tinnitus has already been assigned the maximum schedular rating available under 38 C.F.R. § 4.87, DC 6260. There is no legal basis upon which to award more than a 10 percent rating. Accordingly, the Veteran’s appeal must be denied. Sabonis v. Brown, 6 Vet. App. (1994). REASONS FOR REMAND Entitlement to service connection for sleep apnea, to include as secondary to tinnitus, is remanded. At the hearing before the undersigned, the Veteran contends that his sleep apnea condition began in service or is due to his service-connected tinnitus. See Hearing Transcript, 19-20. VA treatment records showed that he a current diagnosis of sleep apnea. See April 2016 CAPRI. A VA examination and opinion would be helpful in determining whether this condition is related to his tinnitus. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). In addition, on remand, the RO is asked to locate and attach the sleep study conducted in August 2014. See April 2016 CAPRI. Entitlement to a compensable rating for residuals of a circumcision. The Veteran seeks a higher rating for his service-connected residuals of a circumcision. Review of the file shows that the original March 1998 rating decision granted service connection with a noncompensable rating based on noncompensable scar residuals and due to the lack of evidence of a penile deformity with loss of erectile power. The rating decision reflects that the ‘scars’ were based on residual skin bridges that did not result in the deformity of the male reproductive organ but rendered him prone to infection and irritation occasionally. The noncompensable rating was assigned, by analogy, to the rating criteria for deformity of the male reproductive organ (DC 7522). The Veteran most recently underwent VA examinations in September 2013 and April 2016. At the September 2013 examination, a penile deformity with loss of erectile power was not found. The April 2016 VA examination report shows that examiner did not conduct a physical inspection of the Veteran’s penis. With respect to dermatologic residuals, the Veteran reports current and chronic symptoms. In June 2018, he testified that his skin breaks open along the suture line and that he has scarring in the area of the circumcision. See Hearing Transcript, 5-6. The September 2013 VA examination reflects the presence of scarring in the dorsal penis; the April 2016 examination does not include any inspection of the skin in that area. Moreover, the RO does not appear to have considered whether the Veteran is entitled to a separate, compensable rating under any relevant skin rating under 38 U.S.C. § 4.118 (Schedule of Ratings-Skin). The Veteran has also not undergone a VA skin examination to adequately examine him in this regard. For these reasons, this issue is remanded for further development. SMC based on loss of use of a creative organ is remanded. SMC is payable at a specified rate if the Veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organs. 38 U.S.C. § 1114 (k), 38 C.F.R. § 3.350 (a). The Veteran asserts that he experiences loss of use of a creative organ due to his circumcision residuals. Medical evidence of record shows the Veteran currently experiences erectile dysfunction. VA examiners, including most recently in September 2013 and April 2016, have indicated that the Veteran’s erectile dysfunction is not related to his service-connected circumcision residuals. The April 2016 VA examiner, however, opined that at least one of the Veteran’s risk factors for erectile dysfunction is medication used to treat his psychiatric disorders. The Veteran is service-connected for schizoaffective disorder, bipolar type. On remand, further clarification is needed to determine whether the Veteran’s erectile dysfunction is at least as likely related to his service-connected psychiatric disorder. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records from the Cleveland VAMC from August 2016 to the present. 2. Take all action necessary to obtain the August 2014 sleep study and associate the report with the claim file. 3. Schedule the Veteran for an examination to assess the nature and etiology of his sleep apnea. The claims folder should be reviewed, including a copy of this Remand. a) The examiner must opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s sleep apnea condition had onset during active service or is otherwise related to service. b) The examiner must also opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s sleep apnea condition is either proximately due to or aggravated beyond its natural progression by his service-connected tinnitus. A rationale must be provided. Also, in answering this question, two opinions are required: one for proximate causation and a second for aggravation. If aggravation is found, then, to the extent possible, the examiner should attempt to establish a baseline level of severity for the sleep apnea prior to aggravation by the tinnitus. 4. Schedule the Veteran for appropriate examinations (e.g. skin and genitourinary examinations) to determine the nature and severity of his service-connected residuals of a circumcision. The claims folder must be reviewed by the examiners. Skin: All appropriate testing must be conducted and complaints and clinical manifestations must be reported in detail. The examiner must describe the nature, current severity, and all dermatologic residuals of the circumcision residuals, to include any scarring. The examiner is advised that a historical review of file shows the Veteran’s circumcision residuals have included recurrent skin bridges with abcess formation and ulceration and skin tags. Also, a September 2013 VA examiner indicated an area of scarring on the dorsal aspect of the penis. The Veteran also recently testified that he experiences recurrent peeling and bleeding in the area of his sutures. Genitourinary: All appropriate testing must be conducted and complaints and clinical manifestations must be reported in detail. a) The examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s current erectile dysfunction is proximately due to his service-connected schizoaffective disorder, bipolar type, to include medications prescribed for his mental disorders? Please explain why or why not. b) If not caused by the service-connected schizoaffective disorder, bipolar type, is it at least as likely as not that it is permanently worsened beyond its normal progression by the service-connected schizoaffective disorder, bipolar type to include medications used for such? Please explain why or why not. c) If the examiner determines that the Veteran has erectile dysfunction related to service or a service-connected disability, please indicate it manifests with a penile deformity together with loss of erectile power. A rationale for any opinions expressed should be set forth. If the examiner cannot provide an above opinion without resorting to speculation, he/she should explain why an opinion cannot be provided (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). (Continued on the next page)   Upon readjudication of the claim for a higher rating for the service-connected residuals of a circumcision, the RO should specifically consider whether the Veteran is entitled to separate and compensable rating for any dermatological manifestations based on the historical review of the evidence, current clinical findings, and lay statements. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Tang, Associate Counsel