Citation Nr: 18157517 Decision Date: 12/13/18 Archive Date: 12/12/18 DOCKET NO. 14-43 944 DATE: December 13, 2018 ORDER Entitlement to service connection for erectile dysfunction is granted. FINDING OF FACT The Veteran’s erectile dysfunction is proximately due to his service-connected major depressive disorder. CONCLUSION OF LAW The criteria for entitlement to service connection for erectile dysfunction have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1974 to July 1994. This matter comes before the Board of Veterans’ Appeals (Board) from an October 2015 rating decision. In May 2018, the Board remanded the matter for additional development. Entitlement to service connection for erectile dysfunction VA received the Veteran’s claim of entitlement to service connection for erectile dysfunction in May 2015. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). In addition, 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). To establish direct service connection, there must be: the existence of a present disability; in-service incurrence or aggravation of a disease or injury; and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Finally, service connection may be established if the evidence of record shows that a disability has been caused or aggravated by an already service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995) The Veteran’s service treatment records are silent for complaints, diagnosis, or treatment for erectile dysfunction. A March 1979 consultation request to a urology clinic reflects the Veteran’s report that he got married nine months earlier and was seeking to have children; he requested a sperm cell evaluation. Following an examination, bilateral testes biopsy, and vasogram, the diagnosis was azoospermia. Subsequent records noted his genitourinary system was otherwise normal and his infertility was not considered disabling. In April 1990, the Veteran sought treatment for left testicular pain and semen mixing with urine. The assessment included left epididymis tenderness; rule out spilling of sperm in urine. Following a one-week course of Doxycycline, his testicular pain completely resolved. During a June 1990 urology consultation, he described discharge of semen with urine only after prolonged abstinence. The impression was probable Sertoli-cell-only syndrome. On separation examination in May 1994, the genitourinary system was reported as normal. Post-service private medical evidence of record indicates the Veteran reported a two-week history of stress, anxiety, and depression after being laid off from his job as a barber. His physician prescribed Prozac (fluoxetine hydrochloride) and referred him for a psychiatric evaluation. Following a February 2011 psychiatry evaluation, the diagnosis was adjustment disorder. A June 2011 VA mental health note reflects the Veteran’s report that he had been stressed out since he lost his job and had started trials of Ambien and Prozac in February 2011; however, he only took each medication a few times. Private treatment records show the Veteran was first prescribed Viagra for erectile dysfunction in July 2012. In December 2015, a private neurologist, G. Balfour, M.D. indicated his “[r]eview of [the Veteran’s] medical records while on active duty shows he developed erectile dysfunction” and he “did see a doctor for his condition” and was prescribed Viagra. Other private treatment records reflect the Veteran was prescribed other medications for psychiatric symptoms, including Lexapro and Remeron, but he took each medication for about two weeks at most. In August 2017, he started taking Zoloft. A July 2018 rating decision granted entitlement to service connection for major depressive disorder, effective November 7, 2017. In compliance with the Board’s remand directives, the Veteran was afforded a VA examination in July 2018 to determine whether his erectile dysfunction was related to complaints of testicular pain, which were noted in his service treatment records. The Veteran stated that his erectile dysfunction began in January 2006, several years after his separation from active service. He also reported having pain in his testicles during military service and undergoing a biopsy during an infertility evaluation. The examiner opined that the etiology of the Veteran’s erectile dysfunction was psychogenic and it was at least as likely as not proximately due to his depression. The examiner also opined that the erectile dysfunction was less likely as not related to the testicular pain and biopsy in service because the examiner was unable to locate evidence of any risk of developing erectile dysfunction after testicular biopsy or due to episodic testicular pain. Finally, in an October 2018 addendum opinion, the examiner opined that erectile dysfunction was less likely as not due to the Zoloft prescribed to treat the Veteran’s depression because the evidence indicated that erectile dysfunction began before the Veteran started taking Zoloft. Based on the evidence of record, the Board finds that service connection is warranted for erectile dysfunction. First, the Board affords no probative value to the December 2015 opinion of Dr. Balfour regarding the onset of the Veteran’s erectile dysfunction because it is factually incorrect. Contrary to the statement that erectile dysfunction was documented in active duty service treatment records, the records do not demonstrate any problems with erectile function. Rather, they document episodes of testicular pain, azoospermia, and probable Sertoli-cell-only syndrome. Moreover, the Veteran himself has dated the onset of his erectile dysfunction symptoms to 2006, as reflected in the July 2018 examination report. (Continued on the next page)   However, the Board does find that the opinion of the July 2018 VA examiner who determined that the Veteran’s erectile dysfunction is secondary to his depression is highly probative and persuasive. Unlike Dr. Balfour’s opinion, the July 2018 VA examiner’s opinion is supported by a medical explanation that is consistent with the remaining record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Thus, the Board finds that there is sufficient basis upon which to award service connection for erectile dysfunction. K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel