Citation Nr: 18158628 Decision Date: 12/18/18 Archive Date: 12/17/18 DOCKET NO. 16-57 756 DATE: December 18, 2018 REMANDED Service connection for nephrolithiasis (kidney disorder), to include as due to exposure to toxic chemicals, is remanded. Service connection for sex drive and hormones (erectile dysfunction), to include as due to exposure to toxic chemicals, is remanded. Service connection for sleep apnea, to include as due to exposure to toxic chemicals, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1974 to February 1978. The case is on appeal from an April 2015 rating decision. 1. Service connection for a kidney disorder. The Veteran asserts that his preexisting kidney disorder was aggravated by his service. In his November 2016 substantive appeal, he stated his kidney disorder worsened while he was on active duty, including after chronic exposure to toxic chemicals such as trichloroethylene (TCE). He noted that his worsening condition led to hospitalization and surgery in service. The Veteran’s service treatment records contain reports of a prior kidney condition, as well as significant in-service complaints and treatment. During the Veteran’s May 1974 report of medical history upon his enlistment, he answered “yes” to “kidney stone or blood in urine.” He reported at twelve years old, he underwent an operation for fibrovascular compression of left ureter with no complications and an uneventful recovery. October 1976 radiographic evidence showed marked dilatation of the collecting elements of the left kidney with nonvisualization of the kidney, pelvis and ureter. December 1976 service records reveal the Veteran received in-patient treatment for his kidneys for approximately two weeks. A December 1976 service treatment record showed the Veteran reported recurring pain on the left side, including dull aches and sharp pain. The record noted increased densities in the lower calyx of the left upper collecting system with no stone formations. The examining clinician stated he could not exclude the possibility of mechanical obstruction at the kidney-pelvis level and secondary inflammatory disease of the left kidney. An October 1977 service record indicated the previously described radiodensities in the distal minor calyx of the left kidney remain essentially unchanged. The examining clinician noted review of previous examination reports back to 1975 show the densities appear somewhat more massive and may represent small staghorn calculi. He diagnosed the Veteran with extensive hydronephrosis of the left kidney and possible obstruction of the left ureter, as well as small staghorn calculi in the inferior calyx of the left kidney. The Veteran was afforded an April 2015 VA examination during which an examiner diagnosed him with hydronephrosis and nephrolithiasis from 1976, as well as status post pyeloplasty for uretero-pelvic junction (UPJ) obstruction from 1962. The examiner noted the Veteran’s medical history and concluded his kidney disorders were not related to service. She indicated prior to service the Veteran had pyeloplasty for UPJ obstruction which is a common congenital deformity. She stated his UPJ obstruction surgery at age 12 would be considered very late in childhood and kidney damage on the microscopic level would surely have occurred. She noted although the Veteran developed UPJ obstruction again during active duty, it is a natural course of history for congenital UPJ obstruction to obstruct later in life. An addendum opinion must be obtained. The Veteran contends his preexisting kidney disorder worsened during service, including from exposure to chemicals, and the record supports he had significant in-service kidney complaints, including two weeks of treatment in the hospital. The addendum opinion should address whether the preexisting kidney disorder(s) was aggravated by service beyond the natural course of progression as a result of claimed chemical exposure. 2. Service connection for erectile dysfunction. The Veteran contends that he suffers from an erectile disorder or erectile dysfunction related to service, to include exposure to hazardous gas such as TCE. The April 2015 VA examiner diagnosed the Veteran with left hydrocele and left varicocele. She further indicated the Veteran has erectile dysfunction. She stated this disorder is not related to his kidney disorder. She indicated the Veteran has primary hypogonadism which likely causes his low testosterone levels, loss of concentration, fatigue and erectile dysfunction. She noted his service separation examination was negative for erectile dysfunction and decreased libido. She stated kidney stones are not shown to cause erectile dysfunction except possibly during painful periods and thus, his erectile dysfunction is not due to his kidney disorder. The April 2015 VA examination report adequately addresses secondary service connection as a theory of entitlement and that the Veteran’s erectile dysfunction is not related to his kidney disorder. However, the examiner did not discuss whether the Veteran’s erectile dysfunction is directly related to service, to include exposure to harmful gas such as TCE. Thus, an addendum opinion is necessary regarding direct service connection. 3. Service connection for sleep apnea. The Veteran indicated in the November 2016 substantive appeal that he has sleep apnea and has been fitted with a CPAP machine. He asserts that he was exposed to hazardous gas such as TCE in service and that the established long-term effects of exposure to gas include sleep disturbances. As there is evidence that the Veteran currently suffers from sleep apnea and that it may be causally related to service, he should be afforded a VA medical examination. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate VA examiner regarding the nature and etiology of the Veteran’s kidney disorder(s). The claims file must be made available to the examiner. The need for an in-person examination is left to the examiner’s discretion. The examiner should determine whether the Veteran’s pre-existing kidney disorder(s) was at least as likely as not aggravated (non-temporary increase in severity) by service and, if so, whether any increase in severity was clearly and unmistakably (undebatable) due to its natural progress, to include from exposure to hazardous gas such as TCE. A rationale for all opinions expressed should be provided. The Veteran’s in-service kidney complaints and treatment should be addressed, including his two-week hospitalization in December 1976. 2. Obtain an addendum opinion from an appropriate VA examiner regarding the nature and etiology of his erectile dysfunction. The claims file must be made available to the examiner. The need for an in-person examination is left to the examiner’s discretion. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s erectile dysfunction had its onset during, or is otherwise related to, service, to include exposure to hazardous gas such as TCE. 3. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his sleep apnea. The examiner should identify if the Veteran has sleep apnea. If so, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea had its onset during, or is otherwise related to service, to include from exposure to hazardous gas. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Isaacs, Associate Counsel