Citation Nr: 1817360 Decision Date: 03/23/18 Archive Date: 04/03/18 DOCKET NO. 14-17 176 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for status post bowel resection with incidental appendectomy. 2. Entitlement to service connection for a kidney condition, to include partial kidney removal. 3. Entitlement to service connection for erectile dysfunction, to include as due to service-connected post-traumatic stress disorder (PTSD). 4. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Nicole Knoll, Agent WITNESSES AT HEARING ON APPEAL Veteran and his wife ATTORNEY FOR THE BOARD Rachel E. Jensen, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from May 1966 to September 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In September 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A copy of the transcript has been associated with the Veteran's claims file. It appears that in a November 2017 statement, the Veteran's representative expressed a desire to withdraw her representation. As this was not in conformity with 38 C.F.R. § 20.608, she remains recognized as the Veteran's representative. The issues of entitlement to an evaluation in excess of 10 percent for status post bowel resection, entitlement to service connection for a kidney condition, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT There is an approximate balance of evidence on the question of whether the Veteran's erectile dysfunction is related to his service-connected PTSD. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria to establish service connection for erectile dysfunction are met. 38 U.S.C. §§ 1101, 1110, 5103, 5103a, 5107 (2012); 38 C.F.R. §§ 3.102, 3.103, 3.159, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Neither the Veteran nor any of his former representatives has raised any issues with the duty to notify or duty to 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."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran has contended that his erectile dysfunction is caused or aggravated by the medications he takes for his service-connected PTSD. He first began treatment for PTSD in 2003 and his VA health providers prescribed various medications to reach the right combination and dosage to treat his symptoms. It is notable that during the same period, he began to take medications to treat his nonservice-connected hypertension, as well. In August 2003, he first stated to VA clinicians that he could not tolerate the Citalopram prescribed for his PTSD symptoms, citing a sexual impact and difficulty urinating. In June 2004, he stated to VA mental health providers that he had no sexual feelings anymore. In September 2004, he reported that a prescription change to Prozac caused sexual dysfunction. In March 2005, he was diagnosed with erectile dysfunction and prescribed medications to treat the disorder. At a March 2011 VA appointment, he reported that decreasing one of his PTSD medications, Paxil, improved sexual functioning but increased his anger. The Veteran continues to undergo treatment for erectile dysfunction. Several medical opinions were obtained to determine the etiology of the Veteran's claimed condition. In December 2009, the VA examiner found no anatomical abnormalities to cause erectile dysfunction. Given that the Veteran takes medications both for service-connected PTSD and nonservice-connected hypertension which are known to have sexual side effects, the examiner could not state definitively that his erectile dysfunction was predominantly caused by PTSD or the prescribed medications, but did state that if not the primary cause, the Veteran's PTSD and treatment thereof did aggravate the condition. Another examiner in December 2009 found that it would be unduly speculative to affirm a nexus between the Veteran's mental health medications and erectile dysfunction, due to the unclear onset of erectile dysfunction and to his hypertension medications. An addendum opinion affirmed that one would have to resort to speculation to state whether the PTSD medications or the hypertension medications or both combined were the cause of the Veteran's erectile dysfunction. The Board finds that the evidence is in relative equipoise as to whether the Veteran's erectile dysfunction is due to his PTSD and treatment thereof. He began treatment for PTSD and nonservice-connected hypertension with prescription drugs that have known sexual side effects at the same point in time, which is when he also began noting sexual dysfunction. Although not a medical professional with requisite knowledge to diagnose the condition, he did contemporaneously report to clinicians his perceived improvement and deterioration of symptoms associated with changes in his PTSD medications and dosages. Though the VA medical examiners could not determine that his erectile dysfunction was definitively caused by the PTSD medications without speculation, aggravation was noted. Resolving all doubt in favor of the Veteran, the Board finds that service connection for erectile dysfunction on a secondary basis is warranted. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. at 49. ORDER Service connection for erectile dysfunction is granted, subject to the laws and regulations governing the award of monetary benefits. REMAND The Veteran last underwent a VA examination to determine the extent and severity of his bowel resection residuals in March 2014. The mere passage of time, alone, since an otherwise adequate examination, does not obligate VA to have the Veteran reexamined simply as a matter of course. However, at the September 2017 hearing, the Veteran claimed additional symptoms, including pain and difficulty with bowel movements, and his representative asserted in an August 2015 statement that the last VA examination did not accurately depict the extent of his symptoms. Additionally, the Veteran has other gastrointestinal diagnoses that should be discussed in relation to his bowel resection residuals. He has related problems with constipation from some of his prescribed medications for nonservice-connected disabilities, including Pantoprazole for gastroesophageal reflux disease (GERD) and various pain medications. See March 2014 VA examination report, April 2015 VA treatment records. Accordingly, remand is necessary for a new examination and clarification of symptoms. See Snuffer v. Gober, 10 Vet. App. 400, 402-03 (1997). In general, the Board has a duty to discuss all theories of entitlement reasonably raised by the record. See Robinson v. Mansfield, 21 Vet. App. 545, 553 (2008). The Veteran has contended that renal lesions and tumors he has suffered post-service are related to the bowel mass which was removed in service. There is no objective medical opinion of record discussing the etiology of the Veteran's current kidney condition. The low threshold warranting remand for a VA examination has been met. McLendon v. Nicholson, 20 Vet. App. 78, 81-86 (2006). Therefore, a VA examination to determine the etiology of the Veteran's kidney disorder should be sought. The Veteran has claimed that his service-connected disabilities render him unemployable. He is currently service connected for PTSD at 70 percent disabling, status post bowel resection at 10 percent disabling, and scars at 10 percent disabling, thereby meeting the threshold for a schedular TDIU. There are several opinions in the record indicating that the Veteran is unemployable due to a combination of his service-connected and nonservice-connected disabilities. As there are issues still on appeal which may affect the Veteran's claim for a TDIU, the Board finds that the claim is inextricably intertwined and must be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The Veteran last underwent a VA PTSD examination in November 2013. He has expressed the worsening of symptoms. See September 2017 Hearing Testimony. As a full disability picture is needed to determine whether the Veteran is unemployable due to his service-connected disabilities, an additional VA PTSD examination is needed upon remand to determine the extent of his disorder and its effect on his employability before any decision on the TDIU claim may be rendered. See Palczewski v. Nicholson, 21 Vet. App 174, 181-82 (2007); Snuffer v. Gober, 10 Vet. App. at 403; Bolton v. Brown, 8 Vet. App. 185, 191 (1995). Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he provide information as to any outstanding records pertaining to his claimed conditions, specifically to include any outstanding private treatment records. He should be asked to authorize the release of any outstanding pertinent non-VA medical records. 2. Attempt to obtain relevant outstanding VA treatment records. 3. Schedule the Veteran for a VA examination by a qualified clinician to determine the severity and extent of the Veteran's service-connected status post bowel resection with incidental appendectomy. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner is asked specifically to address the Veteran's claims regarding difficulties with bowel movements and pain, and to discuss the interplay of the Veteran's prescribed medications. Discussion of the Veteran's gastrointestinal diagnoses and any connection to his service-connected bowel resection residuals is requested. The examiner is also asked to determine the functional and occupational effect of the Veteran's disability. A complete rationale for all opinions expressed should be provided. 4. Schedule the Veteran for a VA examination by a qualified clinician to determine the nature, extent, onset, and etiology of any kidney disorders. The contents of the entire claims file should be made available to the examiner, and the examination report should include discussion of the Veteran's documented medical history and assertions. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. A complete rationale for all opinions expressed should be provided. Although whether the Veteran's bowel resection in service is related to any current disorder may be obvious on the current record to one trained in medicine, it is necessary for purposes of VA benefits claims that a qualified person explain the matter to those untrained in medicine. With that in mind, the examiner is asked to identify all kidney diagnoses and to provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any kidney disorder originated during the Veteran's active service, or is otherwise etiologically related to the Veteran's active service, to include discussion of any relation to the inflammatory mass in the ascending colon or resulting peritoneal adhesions which were removed in service. 5. Schedule the Veteran for a VA examination by a qualified clinician to determine the severity and extent of the Veteran's service-connected PTSD. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. A complete rationale for all opinions expressed should be provided. The examiner is specifically asked to determine the functional and occupational effect of the Veteran's PTSD. 6. Thereafter, readjudicate the issues on appeal. If any benefit sought remains denied, issue a Supplemental Statement of the Case to the Veteran. After allowing an appropriate amount of time for response, return the case to the Board for review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs