Citation Nr: 18157617 Decision Date: 12/13/18 Archive Date: 12/12/18 DOCKET NO. 16-56 480 DATE: December 13, 2018 ORDER Entitlement to service connection for impairment of rectal sphincter control is denied. Entitlement to service connection for a perineal tear with perianal paralysis is denied. Entitlement to service connection for a rectovaginal fistula is denied. Entitlement to service connection for a Bartholin gland cyst with abscess is denied. FINDINGS OF FACT 1. The competent and probative evidence is against a finding that the Veteran's current impairment of sphincter control had its onset in service or is otherwise related to active duty, to include an episiotomy performed in 1989. 2. The competent and probative evidence is against a finding that the Veteran's current perineal tear with perianal paralysis had its onset in service or is otherwise related to active duty, to include an episiotomy performed in 1989. 3. The competent and probative evidence is against a finding that the Veteran's current rectovaginal fistula had its onset in service or is otherwise related to active duty, to include an episiotomy performed in 1989. 4. The competent and probative evidence is against a finding that the Veteran's current Bartholin gland cyst with abcess had its onset in service or is otherwise related to active duty, to include an episiotomy performed in 1989. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for impairment of sphincter control are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 2. The criteria for establishing entitlement to service connection for perineal tear with perianal paralysis are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 3. The criteria for establishing entitlement to service connection for rectovaginal fistula are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 4. The criteria for establishing entitlement to service connection for a Bartholin gland cyst with an abcess are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service in the United States Army from March 1983 to October 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) located in St. Paul, Minnesota. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service Connection The Veteran contends that service connection is warranted for impairment of rectal sphincter control, a Bartholin gland cyst with abcess, a rectovaginal fistula, and a perineal tear with perianal paralysis disabilities. Specifically, the Veteran contends that the disabilities on appeal are the result of an episiotomy performed during child birth in 1989. After review of the evidence, both lay and medical, the Board finds that service connection is not warranted for the disabilities on appeal. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Board notes that impairment of rectal sphincter control, a Bartholin gland cyst, with abcess, a rectovaginal fistula, and a perineal tear with perianal paralysis are not subject to presumptive service connection as chronic diseases. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. As an initial matter, and resolving all doubt in the Veteran’s favor, the Board finds that the Veteran has current diagnoses of impairment of rectal sphincter control, a Bartholin gland cyst with abcess, a rectovaginal fistula, and a perineal tear with perianal paralysis. Specifically, the July and August 2013 VA examiners diagnosed the Veteran with the disabilities. Additionally, at each of the VA examinations, the Veteran reported continued symptoms of impairment of rectal sphincter control, a Bartholin gland cyst with abcess, a rectovaginal fistula, and a perineal tear with perianal paralysis. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran's December 1982 entrance examination is silent for any of the claimed disabilities. On a March 1989 Nursing Referral, the Veteran twice indicated no problems with her pregnancy or delivery. An April 1989 post-partum questionnaire indicated that the Veteran delivered in February 1989 and noted no complications. An October 1990 gynecology screening revealed normal results for the vulva, introitus, vagina, cervix, uterus, adnexa, and rectum. Private treatment records associated with the claims file show treatment for the claimed disabilities. A February 2003 private post-operative report showed the Veteran was diagnosed with a left Bartholin cyst abcess that caused pain. The Veteran underwent a marsupialization of the left Bartholin’s cyst abcess with incision and drainage and irrigation with no complications. In July 2006, the Veteran reported rectal pain with a recurrent abcess in the anterior area of the rectum and posterior vagina for many years. The Veteran reported having the abcess drained three times previously and that it was thought to be a Bartholin gland cyst infection. She further reported a chronic fissure and noticed a mass coming out of the anus. On examination, the private examiner diagnosed the Veteran with a large anterior chronic fissure with large polyp proximal consistent with a 5cm sentinel pile, exposed internal anal sphincter with visible anterior fistula tract into the abcess in the posterior vagina draining through a visible fistula tract, posterior. The Veteran underwent a trans-sphincteric fistula with abscess and a vessel loop was placed to control the infection. An August 2006 post-operative note indicated that the fissure appeared healed but it was possible that it was still present. In September 2006, the Veteran underwent a colonoscopy that showed an ulcerated mucosa present at 8cm proximal to the anus. A 3cm polyp was found at 6cm proximal to the anus and was removed. The private physician then inserted a probe in the base of the vaginal introitus that seemed to go towards the level of the rectal ulceration, but did not penetrate the rectal mucosa. In private progress notes from January 2009, the Veteran reported no abnormal vaginal discharge or pelvic pain. In July 2013, the Veteran underwent a VA rectum and anus conditions examination. The VA examiner diagnosed the Veteran with impairment of rectal sphincter control, per the Veteran’s history and transphincteric fistula, anal-vaginal. The VA examiner then opined that the Veteran’s impairment of rectal sphincter control and transphincteric fistula were less likely than not incurred in or caused by any in-service injury, event, or illness. The rationale provided was that the Veteran’s service treatment records were silent for any complaints of bowel problems and that the record was silent for complaints of bowel problems until 2006. In August 2013, the Veteran underwent a VA gynecological conditions examination. The Veteran reported that since the 1989 birth of her second child, she had experienced difficulty with bowel movements that included frequent bouts of constipation and stool leaking from the vagina since 2007. She further reported Bartholin cysts and abscesses since at least 2003 when she had a marsupialization surgery done on the left side. On examination, the VA examiner was unable to palpitate a fistula and indicated that further testing would be required to verify ones’ existence. The VA examiner diagnosed the Veteran with Bartholin gland cysts and abcess and rectovaginal fistula. The VA examiner opined that the Veteran’s fecal incontinence and bowel disabilities, perineal tear with paralysis, vaginal abcess, cyst, and fistula were less likely than not caused by any in-service event or injury, including the 1989 surgical procedure performed during child birth. The rationale provided was that the follow-up notes from the Veteran’s delivery showed no complaints of the claimed disabilities. The VA examiner added that it was possible for a patient to develop a fistula after an episiotomy, but that it would be caused by poor healing of the cut during the procedure, and would be apparent right away in many cases, but at least within weeks to months of delivery, and the Veteran did not present with complaints consistent with a fistula until 18 years after the procedure. The VA examiner added that the Veteran confirmed the fistula did not present until around 2006. During the examination, the Veteran stated a belief that the frequent Bartholin’s gland abscesses led to the fistula. However, the VA examiner noted that the Bartholin’s gland is located near the opening of the vagina and that the colorectal surgeon described the fistula tract as being near the Pouch of Douglas, located at the top part of the vagina and there was therefore no way that the Bartholin’s gland abcess led to a fistula in the area described. Finally, the VA examiner added that any fistula from an obstetrical origin would occur in the lower third of the vagina, not in the upper vagina where the Veteran’s fistula was. The Board finds that the weight of the evidence is against the finding that the Veteran’s impairment of rectal sphincter control, a Bartholin gland cyst with abcess, a rectovaginal fistula, and a perineal tear with perianal paralysis are causally related to the Veteran’s 1989 delivery with episiotomy. Specifically, the Veteran's service treatment records show follow-up treatment with examinations following the 1989 delivery with no complaints or findings consistent with the currently claimed disabilities. Specifically, the April 1989 post-partum questionnaire indicated that the Veteran delivered in February 1989 and noted no complications. Further, an October 1990 gynecology screening revealed normal results for the vulva, introitus, vagina, cervix, uterus, adnexa, and rectum. In February 2003, 12 years after service, the Veteran was diagnosed with a left Bartholin cyst abcess which medical record indicate was removed without complication. In July 2006, 15 years after service, the Veteran reported rectal pain with a recurrent abcess in the anterior area of the rectum and posterior vagina for many years and a chronic fissure and noticed a mass coming out of the anus. The Veteran underwent a surgical procedure and August 2006 post-operative note indicated that the fissure appeared healed but it was possible that it was still present. Next, the August 2013 VA examiner opined that the Veteran’s disabilities were less likely than not the result of her 1989 child birth with episiotomy. The August 2013 VA examiner had adequate information on which to base the medical opinion and provided an adequate rationale, including an anatomical basis for the conclusions, that is consistent with the facts in this case and is based on medical principles. For these reasons, the Board affords the August 2013 VA examiner's medical opinion great probative weight. Although the Veteran has asserted that the current impairment of rectal sphincter control, a Bartholin gland cyst with abcess, a rectovaginal fistula, and a perineal tear with perianal paralysis are causally related to service, under the facts of this case, as a lay person, she does not have the requisite medical expertise to be able to render a competent opinion regarding the cause of the complex rectal and gynecological conditions. The etiology of the conditions in question are medical questions dealing with the origin and progression of the Veteran's genitourinary system, and were diagnosed primarily on objective clinical findings, including specialized testing that included a colonoscopy. Thus, while the Veteran is competent to relate some symptoms of the genitourinary conditions that she experienced at any time, including pain, and visual manifestations, under the specific facts of this case that include no continuous symptoms in service and no continuous symptoms after service until a specific incident 13 years after service, she is not competent to opine on whether there is a link between the current, specifically diagnosed disabilities and active service because such an opinion regarding causation requires specific medical knowledge and training. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). The Board notes that this finding is further supported by the August 2013 VA examiner’s rationale that found based on the anatomical location of the Veteran’s specific disabilities that a link between them and the 1989 episiotomy was not medically possible. Based on the evidence of record, the weight of the competent and credible evidence demonstrates no relationship between the Veteran's current impairment of rectal sphincter control, Bartholin gland cyst with abcess, a rectovaginal fistula, and a perineal tear with perianal paralysis and active duty service. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for the gynecological and genitourinary disabilities on a direct basis and the appeal must be denied. Because the preponderance of the evidence is against the appeal, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Teague, Associate Counsel